PN 150 Facts and Terms, Hesi PN Practice Exam and Questions, Unit 6 - Foundations of Nursing Practice, Foundations of Clinical Nursing Practice Test 1, Foundations of Nursing Midterm, PN- Fundamentals, Foundations of Clinical Nursing Practice Test 1,...
6 months
rolls from back to front. holds bottle
4 months
rolls from back to side. places objects in mouth
parasomnias
sleep problems that are more common in children than in adults--may have link to SIDS, in older children: somnambulism, night terrors, nightmares, nocturnal enuresis, body rocking, and bruxism (tooth grinding)
client-centered goal
specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function
Science of nursing
the knowledge base for the care that is given
To define the scope of nursing practice To establish a knowledge base for nursing practice To describe nursing's social responsibility
Which phrase describes a purpose of the ANA's Nursing's Social Policy Statement? Select all that apply.
The PN is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client?
Soybeans
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.
(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.
(B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct Answer: B
Morning (AM) care
(after breakfast) -bathing -back massage -special skin measures -hair care and cosmetics -dressing -positioning for comfort -refreshing or changing bed linens -tidying up bedside
Cultural norms of the healthcare system
* Beliefs * Practices * Habits * Likes * Dislikes * Customs
Nursing roles
* Caregiver * Communicator * Teacher/Educator * Counselor * Leader * Researcher * Advocate * Collaborator
Health
* Individually defined * Integrates all the human dimensions * Holistic care is important
Health restoration
* Nursing interventions that are focused on restoring the patient back to their previous level of health * Generally done after the patient has become ill * Includes medications, surgery, treatments, etc.
Healthy People 2020: Leading Health Indicators
* Nutrition, physical activity, and obesity * Oral health * Reproductive and sexual health * Substance abuse * Social determinants * Tobacco use
Legal safeguards
* Patient education * Executing physician orders * Documentation * Adequate staffing * Professional liability insurance * Risk management program * Incident report
Cultural influences
* Peoples' values and beliefs about health, illness, and care for an illness * Develop from cultural and ethnic influences
Nursing interventions
* Perform nursing interventions safely for individuals and families in a variety of settings
Tertiary level of prevention
* Restoration * Care of the dying
Chronic Inflammation
*lasts for weeks, months or years *persistence = injured tissues *predominant cells are lymphs, macrophages *debilitation leads to decreased immunity (i.e. rheumatoid arthritis, TB)
Individual Risk Factors Related to Safety
- Lifestyle - Impaired mobility - Sensory or communication impairment - Lack of safety awareness
Aims to Improve Quality of Care
- Safe: avoid injuries - Effective: provide care based on scientific knowledge - Patient centered: patient values guide all decisions - Timely: reduce wait and delays - Efficient: avoid waste of equipment, supplies, ideas, and energy - Equitable: care does not vary in quality (gender, ethnicity, geographic -location, socioeconomic status)
Medical Asepsis
-"Clean" technique. -Reduces presence of microorganisms. -Prevents spread from place to person or person to person
types of communication
-direct vs. remote -verbal or non-verbal -talking or listening -social communication vs. professional/collaborative
Tripod/Quad canes
-provide a wide base of support -recommended for patients with poor balance
Acute pain
-rapid in onset -varies in intensity and duration -protective in nature
convalescent period
-recovery from the infection
standing order
-routine order that is carried out until it is cancelled by another order
3-6
...
Sources of knowledge
1) Traditional: passed from generation to generation (e.g. "We have always done it this way" 2) Authoritative: comes from an expert and is accepted (e.g. a senior staff member teaches a new nurse) 3) Scientific: new ideas tested and measured by research (evidence based practice)
4 competencies
1) cognitive abilities/skills 2) technical skills 3) interpersonal skills (communication) 4) ethical/legal skills Nurses rely on these skills to achieve goals of practice
What are the professional values of a nurse?
1. Altruism 2. Autonomy 3. Human dignity 4. Integrity 5. Social justice
The nurse would institute which precautions for a client diagnosed with clostridium difficile?
1. Droplet 2. Contact 3. Airborne 4. Neutropenic
A nurse observes that a client receives pain medication one hour ago from another nurse but the client still has severe pain. The nurse has previously observed the same occurrence. On the basis of the nurse practice act the observing nurse things to do which of the following?
1. Report the information to the police 2. Called impaired Nurse organization 3. Talk to the nurses gave the medication 4. Report the information to the nursing supervisor
The nurses assisting with caring for a client Who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check the client:
1. Vital sign. 2. Skin color 3. Oxygen saturation 4. Latest hematocrit level
A clear liquid diet has been prescribed for a client with gastroenteritis. Which item would be the most appropriate to offer to the client?
1. soft custard 2. Orange juice 3. Fat-free broth 4. Stained soup
What is the expected range of intraocular pressure?
10-21 mmHg
What is considered pre hypertension?
120-139/80-89
A client is receiving a Mantoux test for TB screening. Which angle should the PN insert the needle for injection?
15 degrees
How much room do you need to leave between the restraint and the patient?
2 fingers
How often should you remove ted hose?
2 times a day
If a client with CHF has gained 2kg in 24 hours, you would suspect they have retained how much fluid?
2,000 mLs
How long does the proliferative stage of healing last?
3-24 days
What angle is the head of the bed raised to in Semi-Fowler's position?
30 degrees
For accurate blood pressure measurement, the nurse should inflate the blood pressure cuff ______ beyond the last measurement on the manometer at which she was able to palpate a pulse.
30 mm Hg
Normal values of red blood cells
4 to 6 million/microliter
What percentage of medication errors are a cause of interpersonal communication?
60%
MSN
A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in nursing is necessary to practice at this level?
What are the final parameters that produce blood pressure? (select all that apply) A. Heart rate B. Stroke volume C. Peripheral resistance D. Neuroendocring hormones E. Muscle tone
A. Heart rate B. Stroke volume C. Peripheral resistance
Which organ lays retroperitoeally? A. Kidneys B. Testicles C. Urinary bladder D. Pancreas
A. Kidneys
The nurse can also refer to the external ear as what other known name... A. Pinna B. Malleus C. Incus D. Cochlea
A. Pinna
To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply) A. Posterior tibialis artery B. Politeal artery C. External femoral artery D. Dorsalis pedis artery E Radial artery
A. Posterior tibialis artery, D. Dorsalis pedis artery
Delirium
Acute, temporary, and usually relates to other psychologic conditions.
ANA =
American Nursing Association
used to treat ventricular fibrillation and unstable ventricular tachycardia
Amiodarone
Deontologic =
An action is right or wrong independent of its consequences.
Knowledge
An awareness of the reality one acquires through learning or investigation
Hydrocolloid Dressing
An occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a seal at the wound's surface to prevent evaporation of moisture from the skin
What does an otoscope show?
An otoscope allows visualization of the external auditory canal, the tympanic membrane (TM), and malleus bone visible through the TM
channels of communication
Auditory: spoken words and cues Visual: sight, observations, and perception Kinesthetic: touch *nurses use all three*
Positive finding for guaiac smear on stool specimen
Blue
2+ pulse means
Brisk, expected
What color does levodopa turn your urine?
Brown/black
Most Frequent Type of Health Care-associated Infections (HAIs)
Catheter-Associated Urinary Tract Infection (CAUTI). Represents as much as 80 percent of HAIs in hospitals.
Interventions for a stage 3 pressure ulcer
Clean and/or debride: Prescribed dressing. Surgical intervention. Proteolytic enzymes.
Dispersion of heat by air currents (wind blowing across exposed skin)
Convection
Which structures are located in the subcutaneous layer of the skin? A. Sebaceous and sweat glands B. Melanin and Keratin C. Sensory receptors and hair follicles D. Adipose cells and blood vessels
D. Adipose cells and blood vessels
The nurse should perform oral suctioning for a client with what problem? A. Atelactasis B. Dysphasia C. Gastric reflux D. Dysphagia
D. Dysphagia
The nurse is preparing a client for a bone marrow aspiration. Which erythropoietic site is most likely to be used to obtain the specimen? A. Vertebrae B. Ribs C. Cranial bones D. Iliac crest
D. Iliac crest
Which nonfood item is the most common cause of respiratory arrest in young children? A. Broken rattles B. Buttons C. Pacifiers D. Latex balloons
D. Latex balloons
Which membrane lines the abdominal cavity? A. Perineum B. Pericardium C. Pleura D. Peritoneum
D. Peritoneum
5 Stages of Grief
Denial, anger, bargaining, depression, acceptance
The PN identifies a clients need for spiritual support. What is the first action the PN should take?
Determine the clients perceptions and belief systems.
Symptoms + BG >=200ml/dl at any time w/o regard to meal 2hr post-load glucose >200 (oral gluc test) fasting >126
Diagnostic Criteria
What are the four D's of negligence/malpractice?
Duty Dereliction Damages Direct cause
Dispersion of heat through water vapor (sweating)
Evaporation
The PN obtains an elevated blood pressure reading for an older male client is is alert. When the PN offer the client his morning blood pressure medication, he refuses to take it. What action should the PN take?
Explain the importance of routine use of antihypertensives.
suspension
Finely divided, undissolved particles in a liquid medium; should be shaken before use
Justice =
Give each his or her due and act fairly
Hypoglycemia
Glucagon is used primarily to treat a patient with
HIPAA =
Health Insurance Portability and Accountability Act
A family member of a dying client asks the PN if the client knows the family is at the bedside. The PN explains that which of the five senses persist the longest during the dying process?
Hearing
The practical nurse is caring for a client who is admitted with influenza and vomiting for 3 days. The clients skin turbot is poor and oral mucous membranes are dry. Which finding is most important for the PN to report to the charge nurse?
Hypotension and tachycardia
When should some acceptance be noticed in normal grief?
In 6 months
Growth
Increase in body size or changes in body cell structure, function, and complexity
What is Mintzberg's contemporary model?
Informational, People, Action
Lente, NPH Onset: 2-4 hrs Duration: 16-20 hours Peak: 4-12 hours
Intermediate
What does tonometry measure?
Intraocular pressure
Health
Is a subjective state - a person may be medically diagnosed with an illness but still consider himself or herself healthy
What is the code of ethics for nurses?
It is a succinct statement of the ethical obligations and duties of every nurse
What is fidelity?
Keeping ones promises/commitments
Fidelity =
Keeping promises; "Integrity"
What are the principles of assigning tasks?
Know the nurse practice act in the state you are licensed Cannot assign assessment, planning, evaluation, or accountability tasks Person who it was assigned to cannot assign it to another person
Recognizing Infection
Local or systemic Patient information, clinical appearance (objective and subjective) Vital signs Lab values CBC (Complete Blood Count) Culture reports
When to use? Morphine, O2, nitroglycerin, aspirin
MONA
Larger vessel damage
Macroangiopathy
What is used to document medication administration?
Medication Administration Record (MAR)
Disease in blood vessels, in SMALLER (eyes, diabetic retinapothy)
Microangiopathy
blood seeps & protein leaks out, leads to blindness (diabetic retinapothy)
Microvascualr Angiopathy
Nursing is . . . .
NOTHING without critical thinking!
Patient Safety according to IOM
New standard for quality care—care that is free of unintended injury from acts of commission or omission, in any setting in which it is delivered.
pH
Normal arterial blood pH is 7.35 - 7.45; acidic is less than 7.35 and alkaloid is greater than 7.45
Acid Base Imbalances
Normal pH 7.35-7.45 Acidosis <7.35 Alkalosis >7.45 Lungs regulate pH using CO2 Kidneys regulate pH using HCO3
Motor/expressive aphasia pain scale
Numeric
Health
Nurses promote this by maximizing the patient's own individual strengths
A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the PN priority intervention?
Obtain orthostatic blood pressures.
Cultural assimilation
One's values are replaced by the values of the dominant culture
Development
Orderly pattern of change in structure, thoughts, feelings or behaviors resulting from maturation, experiences, and learning
Describes the interactions between medications and target cells, body systems, and organs to produce effects.
Pharmacodynamics
What are three medications that change the urine color?
Phenazopyridine, amitriptyline, levodopa
An older client who complains of dry mouth is having trouble swallowing pills. What action should the PN take when administering an enter-coated tablet?
Place the whole tablet in a spoonful of pudding.
What enteral formula is nutritionally complete?
Polymeric
extended release
Preparation of a medication that allows for slow and continuous release over a predetermined period; may also be referred to as CR or CRT (controlled release), SR (sustained or slow release), SA (sustained action), LA (long acting), or TR (timed release)
A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the PN implement to maximize the client's oxygenation?
Provide oxygen during rest periods between suctioning.
What is the most important piece of the code of ethics for nurses?
Provision 1.5
QRS always widened Treat with lidocaine Irregular rythm Can lead to vtach or vfib
Pvc
Which growth and developmental characteristics should the PN consider when discussing spiritually with an adolescent client?
Questions religious practices and values.
Onset: 10-15 m Duration:2-4 hours Peak:1 hours Lispro (Humalog), Aspart, Apidra Give with breakfast
Rapid Acting
Acetaminophen is prescribed for an unconscious client with a temp of 104' F. Which route should the PN plan to administer this medication?
Rectal
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.
Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Correct Answer: B
Human Dignity =
Respect for inherent worth and uniqueness of individuals and populations
Autonomy in bioethics =
Respect rights of patients to make health care decisions
How do you measure ventilation?
Respiratory rate, rhythm, and depth
What is autonomy?
Right to make own decisions; of sound mind
Six Rights of Medication Administration
Right: -Patient - 2 identifiers! -Drug -Dose -Route -Time -Right documentation ...right to refuse
At what temperature should enteral solutions be before giving?
Room temperature
Which information should the PN provide a client who is selecting a site for self injection of insulin?
Rotate sites with the same location for a week before choosing a new location
How would a nurse position a pt to maximize the effectiveness of incentive spirometry?
Semi-Fowler's
Regular(Humalin), Semilente Onset: 1-1.5 hr Duration: 4-6 hours Peak: 2-3 hours
Short Acting
powder
Single or mixture of finely ground drugs
Heart isnt beating fast enough to circulate O2, atropine
Sinus brady
What condition is characterized by more than five breathing cessations lasting longer than 10 seconds per hour during sleep, resulting in decreased arterial oxygen saturation levels.
Sleep apnea
Stages of illness
Stage 1) experiencing symptoms Stage 2) assume sick role Stage 3) assume dependent role Stage 4) recovery and rehabilitation
What is a law?
Standard or rule of conduct established and enforced by government.
Autonomy =
Standing alone; independence; right to self-determination
Advocacy =
Standing up for someone, other than oneself, when they are unable, or not prepared, to make a decision, or action, for themselves.
The T wave depicts the relative refractory period, representing ventricular repolarization
T Wave
True
T or F - Telling an agitated patient that an oral sedative is a medication for his headache would be considered fraud.
What are the 5 rights to safely assign tasks?
Task Person Circumstance Communication Supervision
Integrity
The American Association of Colleges of Nursing identified five values that epitomize the caring professional nurse. Which of these is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice?
Nursing
The care of others
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150
What is autocratic leadership?
The leader exerts complete control; direct commands.
What is provision 8 of the code of ethics?
The nurse collaborate with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
Negligence
The nurse places a heating pad on the leg of a patient with PVD to relieve muscle spasms. The pad causes a burn which becomes infected requiring a skin graft. This is an example of
What should the TM look like?
The tympanic membrane should be pearly gray and intact. It should provide complete structural separation of the outer and middle ear structures
What is the purpose of HIPAA?
To ensure patient rights.
Social justice -
Upholding moral, legal, and humanistic rights
What are the two basic theoretical frameworks of ethics?
Utilitarian and Deontologic
The exchange of oxygen and carbon dioxide in the lungs.
Ventilation
The PN is preparing to reconstitute a drug from powder form for IM administration. Which step should the PN implement first?
Verify the drug with MAR
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?
Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference. Correct Answer: B
What is moral distress?
When the nurse knows the right thing to do but either personal or institutional factors make it difficult to do the right thing.
When should the provider be notified of residual with enteral feedings?
When the residual is >250mL for 2 consecutive assessments
Florence Nightingale
Which nurse who was influential in the development of nursing in North America is regarded as the founder of American nursing?
When pouring solution into a cup on the sterile field, how should you hold the solution?
With your hand over the label
During the insertion of a NGT into the right nares, the client starts to cough. Which action should the PN implement?
Withdrawal the NGT to the oral pharynx, reposition the clients head and reinsert.
The role of the nurse was broadened
World War II had a tremendous effect on the nursing profession. Which development occurred during this period?
An older male client who is incontinent receives a prescription for a condom catheter. Which steps should the PN implement when applying the external catheter.
Wrap the adhesive strip in a spiral around the penis Apply skin prep to the penile shaft and allow to dry Leave 1-2 inches between the tip of the penis and condom catheter
Hyperventilation
a state of ventilation in excess of that required to eliminate the carbon dioxide produced by cellular metabolism
toddler psychosocial development
according to Erikson is autonomy vs shame and doubt. idependence is paramount for the toddler who is attempting to do everything for himself, separation axiety continues to occur when parent leaves
When transferring a pt from the bed to the stretcher, where should the pt keep his arms?
across the chest to prevent injury
independent nursing intervention
actions that a nurse initiates
What is copayment?
amount insured person must pay at the time of service
body size
an obese person requires longer needles to reach the muscle than does a thin person.
What are some early symptoms of alcohol withdrawal?
anxiety, irritability, aggression
nursing intervention
any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
toddler body-image changes
appreciates the usefulness of various body parts, develop gender identity by 3 years.
Signs and symptoms of Hypoxia
apprehension, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes, increased pulse rate and increased rate and depth of respiration
The pt's output should _____ the daily fluid intake
approximate
18 months
assumes standing position. jumps in place with both feet. manages spoon without rotation. turns pages in book two or three at a times
Romberg's test assesses for alterations in _____.
balance
7 months
bears full weight on feet. moves objects from hand to hand
What is utilitarianism?
behaviors are determined by either right or wrong based on consequences; "greatest amount of good for greatest amount of people"
phenazopyridine class
bladder analgesic
database
built during assessment, concerns the client's perceived needs, health problems, and responses to these problems
self-concept development
by the end of the first year, infants will be able to distinguish themselves as being separate from their parents
Essence of nursing
caring for, caring with, and caring about people
single or one time order
carried out only once, at a time specified by the prescriber
10 months
changes from prone to sitting position. grasps rattle by its handle
subjective data
client's verbal description of their health problems, will include feelings perceptions, and self-report of symptoms
sources of data
client, family and significant others, health care team medical records, nurse's experience, other records and literature
pallitative care
comfort measures
Altruism =
concern for welfare and well-being of others
What is an interprofessional approach to planning all phases of client care?
critical pathway
Patients undergoing chemotherapy should avoid ____.
crowds
Chemotherapy patients should be encouraged to bathe how often?
daily with antimicrobial soap
Tachycardia is a sign that indicates ____ oxygen to the tissues.
decreased
nursing assessment
deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
What would a Rinne test look like for a pt with sensorineural hearing loss?
demonstrates expected response of air conduction is greater than bone conduction (AC > BC), but length of time is decreased for both
mydriasis
dilation of the pupil
What kind of moisture barrier should you use on patients that are incontinent?
dimethicone-based or alcohol free. Do not use baby powder because of the grit
What is nonmaleficence?
duty to do no harm
toddler moral development
egocentric- unable to see anothers perspective; they can only view things from their point of view.
Safe use of the oxygen concentrator includes assessing the _______ of the device.
electrical appropriate function
With what condition is intraocular pressure elevated?
elevated with glaucoma, especially angle-closure glaucoma.
Reflective practice is . . .
essential to professional practice.
North American Nursing Diagnosis Association (NANDA)
established to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
Bioethics =
ethics dealing with human lives
How often do you need to get a new rx for restraints on a pt aged 9-17 years old?
every 2 hours
Impaired ventricular contractions produces ____ heart sounds.
extra
moderate anxiety symptom
facial twitching
toddler age-appropriate activity
filling and emptying containers, playing with blocks, looking at books. playing with toys that can be pushed and pulled, tossing a ball
When transferring a pt from the bed to the stretcher what should the nurse ask the pt to do with his neck?
flex to avoid injury
What may increase the rate of vomiting in a pt with an NG tube?
flushing the tube with water
What kind of foods should a patient on a clear liquid diet avoid?
foods that are liquid at room temp and are not clear
A pt receiving chemotherapy is encouraged to avoid what kinds of food?
fresh fruits
Oxybutynine contraindications
glaucoma
Lifestyle factors affecting oxygenation
habits such as cigarette smoking or unhealthy diets; nutrition, exercise, smoking, substance abuse, stress
What questions does the CAGE questionnaire ask?
have you ever felt that you need to cut down have you been annoyed by people have you felt guilty have you ever used a substance as an eye opener in the morning
What is the Trendelenburg position?
head below feet
Phenazopyridine contraindications
hepatic disorders and renal insufficiency
What position should a client be sitting in when inserting an NG tube?
high Fowler's
ascitis
high fowlers position
Hypoxia
inadequate tissue oxygenation at the cellular level, results from a deficiency in oxygen delivery or oxygen utilization at the cellular level-life threatening condition
The schedule of blood glucose monitoring is _____ to the needs of the client
individualized
Disparities =
inequality
Developmental Factors affecting oxygenation
infants and toddlers (upper respiratory tract infection), school age children and adolescents (smoking-respiratory infections), young and middle age adults (lifestyle factors-affect cardiopulmonary health)
COMFORT scale
infants, children, adults who are unable to use NRS or Wong Baker FACES pain rating scale
Purulent exudate at the IV site indicates ____.
infection
systemic infection
infection that affects the entire body instead of just a single organ or part, can become fatal if left untreated
mild anxiety symptoms
insomnia
Torts may be . . .
intentional or unintentional.
collaborative intervention
interdependent, therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
Infants have ____ breathing patterns.
irregular
What is laissez-faire leadership?
laid back with no direction
generic name
legal noncommercial name for a drug
arterial blood gases
metabolic alkalosis-pH greater than 7.45
What are unintentional torts?
negligence and malpractice
Normal values white blood cells (leukocytes)
normally 5000 to 10,000/microliter, can rise up to 15,000 to 20,000/microliter and higher during inflammation, high white blood cell count can indicate infection
What is coinsurance?
once deductible is met, it is the percentage of total bill paid by the insured person
Chronic/Episodic
pain that occurs sporadically over an extended duration of time, may last for hours, days, or weeks (migraine headaches)
Warmth at the IV site indicates ____.
phlebitis
Nursing . . .
predates written history.
Before suctioning a pt with a tracheostomy, the nurse should _____ the pt.
preoxygenate
reflex vasocontriction
prolonged heat- decreases blood flow to injured area
Transfer of heat from one object to another without the objects touching each other
radiation
3 months
raises head and shoulders off mattress. no longer has a grasp reflex, keeps hands loosely open
What does dopamine do?
regulates pleasure and pain and plays a major role in addiction
What is deontology?
rightness or wrongness of individual behaviors, duties, and obligations
nursing action for hypoventilation
same as atelectasis, add diaphragmatic breathing-if possible, check on oxygen therapy
What is chiding?
scolding
A patient's ____ is the most reliable pain indicator?
self-report
Nursing is a profession dedicated to . . .
serving others.
Values =
shape our choices, behavior, and identity
STAT order
single order carried out immediately
12 months
sits down from a standing positionn without assistance. tries to build a two-block tower without success
8 months
sits unsupported. begins suing pincer grasp
hypersomnolence
sleep problems from inadequacies in either quantity or quality of nighttime sleep on a daily basis
When performing Romberg's test on a pt, what would the nurse have them do?
stand with arms at side and feet together
sign of infiltration
swelling, hardness or pain located around insertion site
positive Chvostek's sign
tapping on the facial nerve triggering facial twitching
dysphagia
tart and sour food stimulate saliva production which helps with chewing and swallowing
What does gonioscopy allow visualization of?
the iridocorneal angle or anterior chamber of the eyes
0 grade pulse means
the pulse is absent
What kind of muscle movement is an expected finding when breathing?
thoracic
prolonged exposure to cold
tissue eschemia and increased blood viscosity
What is the role of the ethics committee?
to prevent legal issues that often come from ethial dilemmas
Parts of needle and syringe
touch only outside of syringe barrel and handle of plunger (sterile) avoid letting unsterile object touch tip or inside of barrel, hub, shaft of plunger, or needle
What tool is used to perform Weber's test?
tuning fork
What is Naltrexone (Revia)?
used to treat or eliminate alcohol cravings
During immediate postoperative period, which condition has the highest priority when planning Nursing care? A. Infection B. Respiratory obstruction C. Dehydration D. Cardiac arrest
B. Respiratory obstruction
The nurse is caring for a primagravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse? A. Pulse rate of 90 beats/minute B. Rubor lochia saturating 3 perineal pads per hour C. Complaints of perineal pain D. Firm fundus between umbilicus and the symphysis pubis
B. Rubor lochia saturating 3 perineal pads per hour
The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best Nursing action? A. Approach the individuals involved and ask them to stop B. Write an incident report and submit it to the unit manager C. Tell the client of the UAPs concern for him D. Try not to listen to the conversation since it is confidential
B. Write an incident report and submit it to the unit manager
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets.
C) 1½ tablets
A female client is being prepared for a speculum exam. In which position should the nurse place the client? A. Left Sims B. Semi-Fowler's C. Lithotomy D. Trendelenburg
C. Lithotomy
A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should action should the nurse take? A. Report the UAP's omission to the charge nurse B. Complete an unusual occurence report C. Supervise the UAP after reviewing the protocol D. Assign the UAP to more stable clients the next day
C. Supervise the UAP after reviewing the protocol
A client is prescribed a medication that is labeled as a sustained released (SR). What action should the PN implement when administering this drug form?
Do not crush or dissolve the table or capsule contents
Medication Administration: Delivery System
Drug administration and security: -Drug handling -Dosage measuring -Obtaining the drug -Systems used to dispense the drug -How to document drug therapy on the MAR (medication administration record)
How often should you remove abdominal binders?
Every 2 hours
When are trough levels drawn?
Immediately before the next dose of medication
Increased SVR would do what to blood pressure?
Increase it
Chain of Infection
Infection occurs in a cycle that depends on the presence of: Infectious agent or pathogen, Reservoir or source for pathogen growth, portal of exit from the reservoir, mode of transmission, portal of entry to a host, susceptible host
Which position is best for the PN to place the client in during administration of a rectal suppository for constipation?
Left sims position with upper leg flexed.
Inductive reasoning
One builds from specific ideas or actions to conclusions about general ideas
The flow of blood to and from the pulmonary capillaries
Perfusion
an alteration in the inner ear that involves cranial nerve VIII or cochlear damage.
Sensorineural hearing loss
Recognizing Inflammation
Swelling Redness--Hyperemia Heat Pain/Tenderness Loss of Function
The PN is applying a dry, sterile dressing to a clients abdominal wound. Which allergy should the PN verify with the client?
Tape
Desmopressin Why?
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
What is provision 5 of the code of ethics?
The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character, and integrity, maintain competence, and continue personal and professional growth.
What is provision 1 of the code of ethics?
The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
What is provision 3 of the code of ethics?
The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
What is provision 2 of the code of ethics?
The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.
What is provision 7 of the code of ethics?
The nurse, in all roles and settings, advance the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
What is provision 9 of the code of ethics?
The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
What are Nurse Practice Acts?
They are laws established in each state in the United States to regulate the practice of nursing.
Necessary Loss
This is a loss related to a change that is part of the cycle of life that is anticipated but still may be intensely felt. This type of loss can be replaced by something different or better.
The PN is adding tap water to several medication for administration via feeding tube. Which preparation should the PN administer without delay?
Time release capsule
Treat: Sulfonurea (Increase insulin) + biguanide (incr. isnulin sensitivity), diet & exercise
Type 2
health promotion nursing diagnosis
a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise
related factors
a condition or etiology identified from the client's assessment data, associated with the client's actual or potential response to the health problem and can change by using nursing interventions
insomnia
a symptom clients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep (most common complaint)
What is medicare part D?
covers portion of prescription expenses
What is being tested when touching a pt's face with a cotton ball?
cranial nerve V
toddler language development
inceases to about 400 words, speaking in two to three word phases
Cataracts
opacity of lense
weber test
place a vibrating tuning fork on top of the clients head. ask the client if the sound is heard best in the right ear, left ear, or both ears equally. -sound is heard equally in both ears
9 months
pulls to standing position. has a crude pincer grasp
Before suctioning a tracheostomy, the nurse should lubricate the end of the suction catheter with ____ or _____.
sterile water or normal saline
A pt using a cane should use it on the ____ side of the body.
stronger
cutaneous pain
superficial pain usually involving the skin or subcutaneous tissue
What does Slit lamp allows visualization of?
the anterior portion of the eye, such as the cornea, anterior chamber, and the lens.
toddle cognitive development
the concept of object permanence is developed fully, have and demonstrate memories of events that relate to them, domestic mimicry is evident (playing house), preoperational thought doesnt allow toddlers to understand other viewpoints, but it does allow them to symbolize objects and people in order to imitate activities seen previously
quantity to be administered
the larger the amount of med to be injected, the greater the capacity of the syringe
ECG
will show findings of dysrhythmias, such as PVCs, ventricular tachycardia, inverted T waves and ST depression
Professional values essential for nurses
* Foundation for nursing practice * Guide "nurses interaction" * 1998: The AACN identified 5 values that epitomize the caring, professional nurse
Factors influencing growth and development
* Genetic heredity * Prenatal * Individual and caregiver factors * Environment * Nutrition * Health and illness * Culture
Good Samaritan Law
* Protects health practitioners when giving emergency aid
Ethical theories: Utilitarian
* The rightness or wrongness of a particular action depends on the consequences
half-life
-amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body
What are the four elements of liability?
1. Duty. 2. Breach of Duty. 3. Causation 4. Damages.
Advocacy is the protection and support of another's rights. Patients with special advocacy needs include the very young and the elderly, those who are seriously ill, and those with disabilities. Effective advocacy may entail becoming politically active.
A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements reflect a correct understanding of advocacy? Select all that apply.
Integrity =
Acting according to code of ethics and standards of practice
When opening a sterile pack, you should open the first flap which direction?
Away from your body
Martha Rogers
* 1970 * Science of Unitary Human Beings * Promote health and well-being
Virtue of nurses
* Virtues are human excellencies, cultivated dispositions of character and conduct that motivate and enable us to be good human beings
Caring in nursing is:
- A way of being, knowing, & doing with the goal of protection, enhancement, & preservation of human dignity. - Action and competencies that aim toward the good and welfare of others.
Evaluation of Drug Effects
-Therapeutic response -Adverse effect (includes side effects) -Interactive effects -Further teaching needs
Computerized automated dispensing system
-technology based on stock supply of unit dose medications -large cabinet is used containing stock medications -system can be accessed with username and password or fingerprint
What are intentional torts?
1. Assault 2. Battery 3. Deceit and misrepresentation 4. Defamation 5. Invasion of property (patients BODY is the property) 6. False imprisonment
Hey client experiences and cardiac arrest. The nurse leader quickly response to the emergency and assigns clearly defined tasks to the workgroup. In this situation the nurse is implementing which leadership style?
1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire
A nurses caring for a client with hyper parathyroid ism. And notes that the client sir calcium is 13. Which medications to the nurse prepared to minister as prescribed to the client?
1. Calcium chloride 2. Calcium gluconate 3. Calcitonin (Miacalcin) 4. Large doses of vitamin D
A client is a lactovegetarian. Which food item with the nurse removed from the tray?
1. Eggs 2. Milk 3. Cheese 4. Broccoli
A nurse is caring for a client Who has hand restraints. The nurse assesses the skin integrity of the restrained hands:
1. Every two hours 2. Every three hours 3. Every four hours 4. Every 30 minutes
And adult client who had preadmission testing before surgery has blood drawn from the determination of Serum electrolyte levels. The nurse identifies which of the following as an abnormal value?
1. Sodium 148 2. Chloride 101 3. Potassium 3.8 4. Bicarbonate 26
solution
A drug dissolved in another substance (aqueous solution)
Spasms in atrial (many pwaves), blood pools-- tx with anticoagulant (warfarin), cardizem, digoxin & cardiovert if symptoms present
A fib
Inflammation
A protective reaction; Can be caused by nonliving agents i.e. heat, trauma; Always present with infection; Infection occurs only through superimposed evasion of microorganisms; It establishes an environment for healing
An older client is receiving NGT feedings for several days. Which finding should the PN report to the healthcare provider?
Abdominal distention and nausea
If the NG tube is not in the correct place, how do you proceed?
Advance it 5cm and recheck
What risk assessment scales are used for pressure ulcers?
Braden, Norton
Indicator of acute pain
Dilated pupils
What should you do before and after each feeding?
Flush the tubing with >=30mL of tap water
Stage 1 pressure ulcer
Intact skin with an area of persistent, nonblanchable redness. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
An older male client tells the PN that his religion does not permit him to bathe daily. How should the PN respond?
Request that the client clarify his religious beliefs about bathing.
Inspection as related to oxygenation
Respiratory rate, rhythm, depth, breathing pattern Skin color Breathing posture Muscles used in breathing Clubbing of finger nails Capillary refill Level of consciousness
Competency =
The ability to do something correctly, efficiently, and successfully.
Use of PPE
The last line of defense against occupational hazards/infectious agents: -gloves -mask -gown -eyewear
Where should the light reflex be visible on the TM?
The light reflex should be visible from the center of the TM anteriorly (5 o'clock right ear; 7 o'clock left ear).
Regardless of the various definitions of nursing, what is the central focus of *ALL* definitions?
The patient.
Rate is verrrry fast Defib, acls, amiodarone
Vfib
brand-name drug
a drug with a registered name or trademark
What size should the catheter be when suctioning a tracheostomy?
half the size of the lumen
position when recovering from general anesthesia
lateral
environmental factors affecting oxygenation
pulmonary disease is higher in smoggy, urban areas than in rural areas; patient's workplace --occupational pollutants include asbestos, talcum powder, dust, and airborne fibers
erythma
redness- indicated underlying infection
The nurse should initiate a referral to what kind of therapy when a pt has difficulty breathing and requires oxygen or treatment?
respiratory
What are ethical dilemmas?
situations that result in a conflict of 2 or more fundamental values.
defining criteria
the clinical criteria or assessment findings that support an actual nursing diagnosis
What is a pulse deficit?
the difference between the apical pulse and the radial pulse
What are prospective payment systems?
they limit the amount paid by insurers, medicare, and Medicaid, so the amount paid for services is determined before giving care
What would the nurse hear when auscultating a pt with asynchronous closure of the aortic and pulmonic valves?
two dub sounds
A pt using a cane should always maintain ______ on the floor
two points of support
What should be done to the NG tube if the pt begins to gag or choke during insertion?
withdraw slightly
What are torts?
wrongful acts that do not involve contracts
What is deductible?
yearly amount person must pay out of pocket for healthcare costs before insurance covers it
Levels of prevention
* Primary * Secondary * Tertiary
Sequencing question or comment
-used to place events in chronological order or to investigate a possible cause-and-effect relationship between events Ex. Patient: I don't feel like myself anymore since I've been taking my blood pressure medicine. I'm tired and don't have any energy. Nurse: Your tiredness began after you started taking your medicine?
Indicator of pain
Dilated pupils
Severe anxiety symptom
Nausea
What should the nurse do if a pt with an NG tube vomits?
aspirate for residual
decreased myocardial contractility
decreased heart rate and hypotenstion
Susceptible Host
depends on the individual degree of resistance to a pathogen (immune response). Factors that influence susceptibility are age, nutritional status, presence of chronic disease, trauma, and smoking
data analysis
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.
Skin blanching at the IV site indicates ____.
infiltration
The nurse should perform direct percussion over the area of the kidneys to evaluate for _____.
inflammation
stomatitis
inflammation fo the mouth -nonacid soft foods
Functions of white blood cells
involved in cellular response of inflammation upon arrival at site; WBC pass through blood vessels and into the tissues; through phagocytosis, neutrophils and monocytes ingest and destroy microorganisms and other small particles
hypokalemia
level below 3.5 mEq/L. result of an increased loss of potassium from the body or movement of potassium into the cells
hypomagnesium
levels less than 1.3 mg/dL
Risks for the Adult
lifestyle habits: alcohol/drug use, and smoking; stress leading to accidents or illnesses, such as headaches, gastrointestinal disorders, and infections
What is the correct motion for the patient to move a walker?
lifting
localized infection
localized symptoms (wound infection) pain and tenderness and redness at the wound site
sodium (Na+)
major electrolyte found in ECF. essential for maintenance of acid-base balance, active and passive transport mechanisms, and irritability and conduction of nerve and muscle tissue. normal levels 136-145 mEq/L
What is medicare part C?
managed care providers
What is Mintzberg's behavioral model?
managers are reactive not proactive; most of their time is spent in relations
standard of care
minimum level of care accepted to ensure high quality of care to clients; defines the types of therapies typically administered to clients with defined problems or needs
What is capitation?
monthly fee a provider is paid for each covered patient
High pitched sounds are _____ to hear.
more difficult
Inserting an implanted port is _____ (within/not within) the scope of practice for an RN.
not within
Placing an endotracheal tube is _____ (within/not within) the scope of practice for an RN.
not within
What does the nurse practice act define?
nursing practice and establishes standards for nurses in each state
The nurse should initiate a referral to what kind of therapy when a pt has difficulty with activities of daily living?
occupational
After a pt expresses concern what kind of response from the nurse is the most therapeutic?
open ended statements
When transcribing medical orders, it is the nurse's responsibility to ensure that the ____ is complete
order
Portal of Entry
organism enter the body through the same routes they use for exiting
What is medicare part B?
out of hospital insurance
PaCO2
partial pressure of carbon dioxide in arterial blood and is a reflection of pulmonary ventilation; normal range is 35 - 45 mm Hg, hyperventilation occurs when the PaCO2 is less than 35mm Hg; hypoventilation occurs when the PaCO2 level is more than 45mm Hg
diagnostic label
the name of the nursing diagnosis as approved by NANDA International, it describes the essence of a client's response to health conditions in as few words as possible
Blended competencies =
the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing
Abraham Maslow
*1968 * Developed a hierarchy of basic human needs that can be used to consider which needs of a person are the most important at any given time
oral drug preparations
-capsule -pill -tablet -extended release -elixir -suspension -syrup
exercise and skin
-increased circulation nourishes skin
reservoirs for microorganisms
-other people -animals -soil -food, water, milk -inanimate objects
Background
-the patients mental status (agitated, confused, lethargic, non-responsive) -the condition of the patients skin (warm, dry, pale, mottled, diaphoretic, cold/warm extremities) -is the patient on oxygen? how many liters? for how long? what is their SPO2?
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube
1 Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result
The PN is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site?
1 inch
And adult client with hepatic cirrhosis has been consuming a diet with optimal amounts protein. The nurse evaluates the client status as most satisfactory if the total protein level is which of the following values?
1. 0.4g 2. 3.7g 3. 6.4g 4. 9.8g
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. 1 Tremors 2 Lethargy 3 Palpitations 4 Visual disturbances 5 Decreased pulse rate
1,3 Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.
An adult male client has had laboratory work done as part of a routine physical examination. The nurse reviews the clients record and determines that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is found?
1. 0.6 mg 2. 1.1 mg 3. 1.9 mg 4. 3.5 mg
The client with diabetes mellitus has a blood sample drawn from the determination of a fasting blood glucose level. The nurse identifies which of the following results As a critical value?
1. 150 mg/dL 2. 200 3. 220 4. 340
A nurse is reviewing the Laboratory results of an adult client with Addison's disease. The nurse determines that the magnesium level is normal if it is which of the following?
1. 2 mg 2. 3 mg 3. 4 mg 4. 5 mg
A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?
1,4 Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.
Hey client scheduled for an arterial blood gas specimen to be drawn, and the nurse assist with performing Allen's test on the client. Remember the steps for performing on testing order priority.
1. Assess the color of the extremity distal to the pressure point 2. Document the findings 3. Apply pressure over the ulnar and radial arteries 4. Explain the procedure to the client 5. Release pressure of the ulnar artery 6. Ask the client open and close the hand repeatedly
A client has acute diverticulitis. which principle should the nurse keep in mind while planning care for this client?
1. Avoid high-fiber foods 2. Use a fluid restricted diet 3. Increased seed and nut intake 4. Increase raw fruits and vegetables
A nurses reviewing the health records of assigned clients. Nurse plans care knowing that which client is at risk for fluid volume defficient?
1. Client was cirrhosis 2. Client with a colostomy 3. Client with decreased renal function 4. Client with congestive heart failure
The client as the student nurse about various herbal therapies available for the treatment of Insomnia. The student could provide information about which of the following?
1. Garlic 2. Valerian 3. Lavender 4. Glucosamine
A nurse is caring for a client who has been taking diuretic on a long term basis. A fluid volume deficit is suspected.
1. Gurgling respirations 2. Increase blood pressure 3. Decreased hematocrit level 4. Increase specific gravity of your
The registered nurse reviews the results of the arterial blood gases with a licensed practical nurse and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to know which of the following on the laboratory result form.
1. PH 7.50, PCO2 52 2. PH 7.35, PCO2 40 2, PH 7.25, PCO2 50 4. PH 7.50, PCO2 30
Which of the fine is recommended guidelines for safe computerizing Charting?
1. Passwords to the computer system should only be changed if lost. 2. Computer terminals may be left unattended during clients care activities 3. Report accident of deletions from the computerized file to the nursing manager or supervisor 4. Copies of printouts from computerized files should be kept on a clipboard at the nurses station for other nurses to excess
A nurse is assigned to care for four clients. When planning client rounds which client would the nurse check first?
1. The client on a ventilator 2. Client in Skelton traction 3. A post operative client preparing for discharge 4. The client admitted on previous shift who has a diagnosis of Gastroenteritis
A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should including a plan of care? Select all that apply
1. Wearing gloves when emptying the clients bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film badge when in the clients room 4. Wearing a lead apron when providing direct care to the client
Atropine Conduction is slow, rate can be normal
1st degree av block
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1 Chlorothiazide (Diuril) 2 Acetazolamide (Diamox) 3 Bendroflumethiazide (Naturetin) 4 Demecarium bromide (Humorsol)
2
A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1 It stimulates plasma cells directly. 2 A high titer of antibodies is generated. 3 It provides immediate active immunity. 4
2 A long-lasting passive immunity is produced. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.
2 Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.
A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin
2 The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.
A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1 Stimulating the urge to defecate. 2 Lubricating the sigmoid colon and rectum. 3 Dissolving the feces. 4 Softening the feces
2 The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.
In what position should the nurse place a client recovering from general anesthesia? 1 Supine Correct2 Side-lying 3 High Fowler 4 Trendelenburg
2 Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing.
The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Incorrect 1 Dyspnea 2 Flushed face 3 Precordial pain 4 Increased pulse rate 5 Increased blood pressure
2,4 Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue
3 A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%
3 Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.
The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1 Protein 2 Glucose 3 Ketones 4 Uric Acid
3 As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine. Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.
A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen
3 Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.
A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis
3 Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.
A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? 1 An acquired atopic sensitization occurred. 2 There was passive immunity to the penicillin allergen. 3 Antibodies to penicillin developed after a previous exposure. 4 Potent antibodies were produced when the infusion was instituted
3 Hypersensitivity results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not passive, immune response. Antibodies developed when there was a previous, not current, exposure to penicillin.
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? 1 Curling ulcer 2 Renal shutdown 3 Metabolic acidosis 4 Hemolysis of red blood cells
3 Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic acidosis. Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse effects of the drugs.
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's 3 End-stage renal 4 Gastroesophageal reflux .
3 One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause
3 Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.
A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1 A defibrillator 2 An IV infusion pump 3 A tracheostomy tray 4 An electrocardiogram (ECG) monitor
3 The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.
Oxybutynine side effects
Increased intraocular pressure, dizziness, tachycardia, constipation
How long does the inflammatory stage of healing last?
3-6 days
What is the acceptable oral temperature range?
36-38 degrees celsius; 96.8-100.4 degrees farenheit
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.
4
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.
4
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force
4
A client has been diagnosed as brain dead. The nurse understands that this means that the client has: 1 No spontaneous reflexes 2 Shallow and slow breathing 3 No cortical functioning with some reflex breathing 4 Deep tendon reflexes only and no independent breathing
4 A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of brain dead.
What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1 6 hours 2 12 hours 3 18 hours 4 24 hours
4 After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.
Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 t
4,5 Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.
Sawtooth Atrial rate 250-350 Ventricular rate is steady Cardioversion, cardizem (verapamil), amiodarone
Atrial flutter
What is a normal blood pressure?
<120/<80
What is considered stage 2 hypertension?
>=160/>=100
Both the nurse and the physician are responsible for their respective actions.
A nurse administers the wrong medication to a patient and the patient is harmed. The physician who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication?
Which nurse's behavior is a breach of client confidentiality according to the Health Insurance Portable Accountability Act (HIPPA) regulations? A. A daily report sheet with the information of the team's clients is taken home. B. Privileged health information (PH) is mailed through the US postal service C. A client is called by both the first and last name in a public waiting room. D. The ambulance health care provider is given information about the client's history
A. A daily report sheet with the information of the team's clients is taken home.
The nurse is administering the shingles vaccine to an older male-client who asks why he should receive the immunization. Which information should the nurse provide? A. A history of chickenpox indicates that the harbors the dormant virus B. The client's last dose of adult immunizations was 10 years ago C. A recent outbreak of fever blisters indicates reactivation of the virus D. Multiple stressful personal experiences increase his risk of shingles
A. A history of chickenpox indicates that the harbors the dormant virus
The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stool softner B. Administer prescribed PRN sleep medications. C. Encourage breastfeeding to promote uterine involution D. Encourage use of prescribed analgesic perineal sprays.
A. Administer Prescribed stool softner
The nurse is preparing a client for an Intravenous Pyelogram (IVP) scheduled for the following morning. What action is most important for the nurse to implement? A. Determine if the client has any allergies to shellfish B. Inform client that an IV dye will be administered before the IVP C. Explain that dizziness may occur when the dye is given D. Administer a bowel prep the evening before the procedure
A. Determine if the client has any allergies to shellfish
36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A. Palpate the bladder for distention B. Ask the client when her last bowel movement occurred C. Catheterize the client and record the amount D. Assess the amount of lochia
A. Palpate the bladder for distention
The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client? A. Upper torso B. Head C. Feet D. Upper extremities
A. Upper torso
suppository
An easily melted medication preparation in a firm base such as gelatin that is inserted into the body (rectum, vagina, urethra)
Neuropathic Pain
Arises from abnormal or damaged pain nerves. Abnormal processing of sensory input by the peripheral or central nervous system; Treatment usually includes adjuvant drugs; A physical cause for reports of excruciating pain may not be evident on examination
A new mother is at the clinic with her 4-week old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2-months of age. A. Turns from side to back and returns B. Consistently returns smiles to mother C. Finds hands and plays with fingers D. Holds head up and supports weight with arms
B. Consistently returns smiles to mother
A client is diagnosed with Clostridium Difficile (CDIFF). What action should the nurse implement to prevent the spread of the organism? A. Place a surgical mask on the client during transport B. Don non-sterile gloves when performing direct care C. Wear a particular respirator mask when in the room D. Keep the door closed to the client's room at all times
B. Don non-sterile gloves when performing direct care
A nurse refuses to perform a procedure because itis beyond the scope of practice for practical nurses. Which resource best defines the nurse's legal responsibility in regard to scope of practice? A. Nursing practice standards for Licensed Practical/Vocational Nurses B. State Nurse Practice Act C. Code of Ethics for Licensed Practical/Vocational Nurses D. Patients Bill of Rights
B. State nurse Practice Act
The PN identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN?
Bowel movements decreases to one every third day.
A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer? A. 0.025 B. 0.0025 C. 0.25 D. 25.0
C. 0.25
Which client should the nurse assign to an unlicensed assistive personnel (UAP)? A. An older male client with melena who is complaining of abdominal pain and needs a guaic test of a stool sample B. A young adult experiencing flank pain and hematuria who needs all urine strained for stones C. A client who has regular heart rate and after a pacemaker replacement now needs to ambulate D. An elderly client with Right-Sided Hemiplegia and Receptive Aphasia who needs to be transfered to the wheelchair
C. A client who has regular heart rate and after a pacemaker replacement now needs to ambulate
The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? A. Raise the bed to ensure the drainage bag remains off the floor B. Attach the drainage bag to the side rail instead of the bed frame C. Observe the appearance of the urine in the drainage tubing D. Secure the tubing to the client's gown instead of his abdomen
C. Observe the appearance of the urine in the drainage tubing
The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is "gurgling" on oral secretions and coughing. Which action should the nurse take first? A. Position the client supine B. Finger sweep the oral cavity C. Perform oral suctioning D. Provide mouth care
C. Perform oral suctioning
What is the function of neutrophils? A. Heparin secretion B. Transport oxygen C. Phagocytotic action D. Antibody formation
C. Phagocytotic action
In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is... A. a 40-year-old African American with Hypertension (HTN) B. a 35-year-old with trauma to the breast C. a 32-year-old whose mother had breast cancer D. a 50-year-old Caucasian who has never had a mammogram
C. a 32-year-old whose mother had breast cancer
The nurse empties a large amount of serous drainage from a postoperative client 's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the bottom.) Compress drain... close drain... discard drain... document
Compress drain... close drain... discard drain... document
client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.
Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the health care provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.
The nurse is providing care for a client receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the RN? A. Warm skin with elastic turgor B. Dry mouth with thirst C. Low grade fever with diaphoresis D. Hives with pruritus
D. Hives with pruritus
A school-aged child with AIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action? A. Obtain penicillin G 1000U weekly B. Obtain the varicella vaccine C. Enroll in a home school program D. Obtain the varicella zoster immune globulin
D. Obtain the varicella zoster immune globulin
A nurse is contributing to a care plan for an adolescent female client with Anorexia Nervosa. Which outcome statement or goal would be most appropriate for this client? A She will participate in a daily aerobic exercise program B. She will consume at least 50 percent of all meals C. Her laboratory values will remain within normal limits D. She will develop a positive body image and self-identity
D. She will develop a positive body image and self-identity
How often should you reposition a client while sitting in a chair?
Every hour
nursing role in pain management
Direct clinical care Patient/family teaching Education of colleagues Identify system barriers
Which intervention should the PN implement to help a client cope effectively with chronic pain?
Encourage using relaxation techniques.
Rewarding and punishing.
Five-year-old Bobby has dietary modifications related to his diabetes. His parents want him to value good nutritional habits and they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission?
infection cycle
Infectious agent, reservoir, portal of exit, means of transmission, portal of entry and susceptible host.
Risks for Infant, Toddler, and Preschooler
Injuries, lead poisoning, accidents due to particular stage of growth--such as oral activity and children possibly ingesting dangerous substances or choking
Ethical distress
Janie wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. She believes his dying is being prolonged painfully. She is troubled when the patient's doctor tells her that she'll be fired if she raises questions about his care or calls the consult. This is a good example of:
Risks within the Healthcare Setting
Medical errors: infection, bed sores, and failure to diagnose and treat in time; medication errors; falls, client-inherent accident; procedure-related accidents; equipment-related accidents
PT with active TB
Negative airflow room pressure
What is unintentional torts?
Negligence & Malpractice
The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria.
P Wave
What types of food (high in what electrolyte) should patients with chronic kidney disease avoid?
Potassium such as cantaloupe, banana, and baked potato
capsule
Powder or gel form of an active drug enclosed in a gelatinous container; may also be called liquigel
NSNA
Prepares students to participate in professional nursing organizations
age-related loss of the eye's ability to focus on close objects
Presbyopia
A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. The client expresses fear about becoming addicted to these drugs. What information should the PN provide?
Prescribe opiates for cancer pain relief improve qualify of life.
The QRS complex represents ventricular depolarization.
QRS Complex
QSEN =
Quality and safety education for nurses
The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing?
Remove all four sides by moving to the center of the incision.
Nurses have a bill of rights that:
Results in advocacy on behalf of the nursing profession. Empowers nurses. Improves workplace. Ensures nurses' ability to provide safe, quality care. Allows them to freely advocate for themselves and their patients, without fear of retribution.
The unlicensed assistive personnel
The patient in Room 406 needs a bedpan. Who you gonna call...
What are some patient rights?
To see and copy their health record. To update their health record. To request correction of any mistakes. To get a list of disclosures. To request restrictions on certain uses or disclosures. To choose how to receive health information
Hr is 150-250 no p wave (cant determine atrial rate) No Pulse: defibrillator, amiodarone, cpr, acls Pulse: cardiovert/amioderano
Vtach
Beneficence =
benefit the patient
actual loss
occurs when something can no longer be felt, heard, or known, as in the loss of a body part
Dorothea Orem
* 1971 * Self-care deficit theory
Ethical decision making
* Ethical dilemmas * Ethical distress
Sentinel event
* JCAHO * An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof * Serious injury specifically includes loss of limb or function * Needs immediate investigation and response * E.g. a baby is stolen from the hospital
Laws affecting nursing practice
* Sentinel events * Good Samaritan Law * Student liability
Pain assessment tools
-Wong-Baker FACES -Beyer Oucher pain scale -CRIES pain scale -FLACC scale -COMFORT scale
injection route of administration
-a longer needle is required for IM compared to intradermal or SubQ
Exercise and Respiratory system
-improved alveolar ventilation -decreased work of breathing -improved diaphragmatic excursion
An adult client was diagnosed with acute pancreatitis nine days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level drops to which of the following values, Which is just beneath the upper limit of normal?
1. 20 units 2. 80 units 3. 135 units 4. 250 units
Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (≤60 beats/minute) rate. Sinus bradycardia is a slower than usual (≤60 beats/minute) heart rate.
A 66-year-old female client is having cardiac diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia did the tests reveal?
Provide the information and support a patient needed to make decisions to advance one's own interests
A professional nurse committed to the principle of autonomy would be careful to:
Battery
A review of a patient's record revealed that she had never consented to the eye surgery, which intentional tort might the surgeon have been guilty of?
Private Law?
AKA: Civil law. Most law associated with nursing. -Regulates relationships among people.
measures to promote sleep
Adequate assessment Plan activities to maximize time for rest and sleep Provide comfort measures Establish sleep environment Patient education
Stereotyping
Assuming groups are alike
A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus C. An infusion of medication in the spinal canal will block pain perception D. The discharge of electricity will distract the client's focus on the pain
B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
Florence Nightingale did many significant things in her lifetime, some of those include:
Challenged prejudices against women. Elevated the status of nurses Established the first "proper" training of nurses. *Based nursing practice on evidence.* Helped distinguish nursing from medicine.
An older female state the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse take?
Check the written prescription to verify the medication
An alteration in the middle ear that blocks sound waves before they reach the inner ear.
Conductive hearing loss
The nursing process is the _____________ for all nursing activities.
Framework
Nurse Practice Act
If you want to find a list of violations that result in disciplinary actions against a nurse, you should read the follow?
Holistic nursing care
Is based on considering all the patient's dimensions that affect how human needs are met in health and illness
An 80 year old male client who has arthritis and who is having difficulty walking tells the PN, "It's awful to be old. It's seems as though everyday is a struggle. No one cares about an old person." What is the best response for the PN to provide?
It's sounds as though you are having a difficult time. Tell me about it.
What post void residual must you have to not have a catheter?
Less than 50 ml
used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation
Lidocaine
clots build up, accelorates athro sclerosis, which can lead to myocardial infarction
Macrovascualr Angiopathy
A nurse is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable. Correct 1. Meta-analysis 2. Randomized controlled trial 3. Expert opinion based on scientific principles 4. Cohort study 5. Controlled trial without randomization
Meta-analysis is a synthesis of evidence from associated randomized controlled trials. Meta-analysis is more reliable than a randomized controlled trial. Randomized controlled trials are studies where subjects randomly are assigned to a treatment or control group. A randomized control trial is more reliable than a controlled trial without randomization. Controlled trials without randomization are studies in which subjects are assigned nonrandomly to a treatment or control group. A controlled trial without randomization is more reliable than a cohort study. Cohort studies observe a group to determine the development of an outcome. Expert opinion based on principles is not based on actual evidence; it is relied on when there is no evidence from research. Topics
Unstageable pressure ulcer
No determination of stage because eschar or slough obscures the wound
Is there one specific route to become an RN?
No! There are various educational routes, however BSN programs are becoming the way of the profession and will soon surpass other routes.
Inferred pain by pathological process
Nociceptive pain--somatic and visceral and neuropathic pain
Pulse Oximetry
Non-invasive Measures arterial oxygen saturation SpO2 Normal is > 95% Ensure accuracy: validate with patient heart rate Ensure accuracy: determine patient's hemoglobin level Continuous, intermittent, or during ambulation
Defining the legal scope of nursing practice
Nurse practice acts are established in each state of the United States to regulate nursing practice. What is a commonelement of every state practice act?
In what ways has nursing evolved?
Nursing is no longer considered a "less than" job and instead is recognized as a highly respected profession. Practice has widened to cover a wide variety of health care settings. Nurses have a specific body of knowledge. Nurses have an ethical conduct. Nurses value research and continuously publish scholarly research. Nurses don't just "care for sick people;" nurse promote health as well. Nursing is continuously growing as a highly professional discipline.
Deductive reasoning
One examines a general idea and then considers specific actions or ideas
Factors That Influence Pain
Physiological factor: age, fatigue, genes, neurological function; Social factors: attention, previous experience, family and social support; Spiritual factors; Psychological factors: anxiety, coping style; Cultural Factors: meaning of pain, acceptable pain expression
interventions to promote sleep
Plan activities to maximize time for rest & sleep Provide comfort measures Establish sleep environment Establish sleep routine Avoid stimulants Avoid exercise 2-3 hours before bedtime Pharmacological approaches
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D). Correct Answer: B
What should you expect stools to look like after a sigmoidoscopy?
Solid and formed
Which stage of sleep is also called Delta sleep?
Stage 4
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.
The client should be positioned in a semi-sitting or Fowler's (B) position during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often referred to as a PEG tube, is inserted directly into the stomach through an incision in the abdomen and is used when long-term tube feedings are needed. In (A and/or C) positions, the client would be lying on his abdomen and on the tubing. In (D), the client would be lying flat on his back which would increase the chance of aspiration. Correct Answer: B
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 faint, barely detectable. 2 slightly weak, palpable. 3 normal. 4 bounding.
The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 + indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.
nonverbal communication
Transmission of information without the use of words, it helps nurses to understand subtle and hidden meanings in what the patient is saying Ex. -touch -eye contact -facial expression -body posture -gestures -physical appearance -voice tone -rate of speech -neatness -movement -electronic communication (social media, email and text messages)
What is the most important for the PN to include when performing pain assessment after giving an analgesic?
Use a pain scale to describe the intensity.
Which action should the PN implement when supporting an older client who is afraid of dying?
Use open-ended questions to encourage the client to share feelings
collaborative problem
an actual potential physiological complication that nurses monitor to detect the onset of changes in a client's status
goal
an aim, intent, or end; a broad statement that describes the desired change in a client's condition or behavior
A pt using a cane should advance the cane while balancing the weight on ______.
both legs
Since Florence Nightingale, nursing has . . .
broadened in all areas.
Infection and Inflammation
can be local, systemic, acute or chronic
Low red blood cell count (anemia)
can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. Red blood cells live for approximately four months in the bloodstream
venturi mask
can provide up to 55% oxygen
simple face mask
can provide up to 60% oxygen
rebreather mask
can provide up to 70% oxygen
nonrebreather mask
can provide up to 90% oxygen
Causes of hypervolemia
chronic stimulus to the kidney to conserve sodium and water (heart failure, cirrhosis, increased glucocorticosteroids), abnormal renal function with reduced excretion of sodium and water (renal failure), interstitial to plasma fluid shifts (hypertonic fluids, burns), age-related changes in cariovascular and renal function, excessive sodium intake
What is a pt encouraged to do when receiving chemotherapy?
clean toothbrush to reduce risk of oral infection
nursing health history
data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
Early morning hyperglycemia resulting from increased growth hormone circulation
dawn phenomenon
nursing action for atelectasis
hypoventilation occurs so best action is to help improve tissue oxygenation, restoring ventilatory function, treating the atelectasis, and achieving acid base balance. use of incentive spirometer, deep breathing and coughing, pursed lip breathing
What are some progressive symptoms of alcohol withdrawal?
increased BP and pulse, tremors, n/v/ diaphoresis, delirium tremors, hallucinations, seizures
serum sodium
increased hemoconcentration. hypervolemia- sodium within expected reference range. levels: 136-145 mEq/L.
integumentary changes
increased pressure on skin, which is aggravated by metabolic changes, decreased circulation to tissue causing ischemia, which can lead to pressure ulcers
types of interventions
independent nursing, dependent nursing, and collaborative interventions
What is a sign that a pt has decreased oxygen to the tissues and the nurse should suction his tracheostomy?
irritability
rhomberg test
measures stability with and without the eyes being closed
syrup
medication combined in a water and sugar solution
bezodiazepines
midazolam (versed) and lorazepan (ativan) are given to reduce anxiety and sedate the PT
Hypoventilation
occurs when alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide
Aspiration
occurs when fluids are breathed into the lungs or airways leading to the lungs
What should be assessed first before assigning a task?
patient stability
The nurse should initiate a referral to what kind of therapy when a pt has difficulty with mobility and strength?
physical
Risks for the Older Adult
physiological changes leading to greater fall risk and other types of accidents such as burns and car accidents
Factors Affecting Oxygenation
physiological, developmental, lifestyle, environmental
rinne test
place a vibrating tuning fork firmly against the mastoid bone and note the time. have the client state when he can no longer hear the sound, note the time and then move the tuning fork in front of the ear canal. when the client can no longer hear the tuning fork, note the time. -air conduction greater than bone conduction 2 to 1 ratio
infants physical development
posterior fontanel closes by 2-3 months. anterior fontanel closes by 12-18 months. gains 5-7 oz per month in first 6 mo. should double by 4-6 mo. grows about 1 inch per month in first 6 mo. then 1.25 till end of year. head: 1.25 per mo then 0.5 after 6 months. 6-8 teeth erupt in first year.
What can the nurse do to help the pt create the sensation to urinate?
pour warm water over perineum
Impaired glucose tolerance 140-199 impaired fasting glucose 110-126 screen at 40 is FHx present encourage weightloss
pre-diabetes
What are regulatory laws?
state boards granted power to make laws that govern their area
Who grants licensure to a nurse?
state boards of nursing
purulent drainage
thick yellow, green, or brown drainage, often associated with wound slough or infection
psychosocial development
trust their feeding, comfort, stimulation, and caring needs will be met. social development is initially influenced by the infants reflexive behavior and includes attachment, separation recognition/anxiety and stranger fear-occurs during first year.
Care team
* Doctors * Nurses * Dietary * Pharmacist * Social worker * Therapist
Florence Nightingale
* Established the first school for nurses that provided both theory-based knowledge and clinical skill building * Stressed the need to create a body of nursing knowledge separate from medical knowledge * Recognized the influence of environment on health * Identified personal needs of the patient and the role of the nurse in meeting those needs * Established standards for hospital management * Established a respected occupation for women * Recognized the 2 components of nursing (health and illness) * Recognized that nutrition is important to health * Stressed the need for continuing education for nurses * Identified that maintaining accurate records is important for nursing research
Nursing code of ethics
* Framework (to make decisions): professional expectations * Goals and values of profession * Protects patients * Nursing Standards of Practice: 1991 standards of professional performance and standards of care
Role of nurse: middle adult
* Health maintenance and promotion * Greater emphasis on both anticipatory guidance counseling * Teaching about illnesses, grand-parenting, retirement, losses, stress reduction
Major health concerns for middle adult
* Heart/pulmonary disease * Cancer/strokes * Diabetes mellitus/obesity * Alcoholism/depression * Accidents
Nursing Theorists
* Hildegard Peplau (1952) * Abraham Maslow (1968) * Martha Rogers (1970) * Dorothea Orem (1971) * Sr. Callista Roy (1974) * Madeline Leininger (1978) * Patricia Benner (1989) * Jean Watson
Community based healthcare services
* Home health care * Hospice: 6 months or less to live * Respite care * Community centers and clinics * Day care programs * Parish nursing * Meals on wheels
Human needs
* Humans are complex organisms, influenced by and responsive to both the internal and external environments * Holistic nuring care allows the nurse to provide individualized and health-oriented care
Healthy People 2020: Leading Health Indicators
* Improve access to healthcare services * Clinical preventative services * Environmental quality * Injury and violence prevention * Maternal, infant, and child care * Mental health and mental disorders
Nursing research
* Improve care of patients by improving quality, cost effectiveness, and safety * Broader study of people and nursing to enhance: education, policy development, ethics, and history
Suicide
* In 2014, the highest suicide rate (19.3) was among people older than 85 * Second highest rate (19.2) was among people ages 45-64 years * Younger groups have had consistently lower suicide rates than middle-aged and older adults (11.6% ages 15-24 in 2014)
Legal safeguards
* Informed consent: confirm * Contracts: exchange of promises (written or oral) * Collective bargaining: unions or other organizations * Competent practice: you're responsible for your own education and updating your practice with continuing educational hours; documentation
Theory of moral development
* Lawrence Kohlberg * Carol Gilligan
Community based care
*Healthcare provided to people who live within a defined geographic area * Each community is unique and is defined by the people, area, social interactions, and common ties * Centered on individual and family healthcare needs
sensory perception and safety
-alterations in sensory perception can have a devastating affect on safety -impairment in sight, hearing, smell, taste, or touch can reduce a persons sensitivity to the environment ex: -not being able to see objects that can be tripped over - inability to hear alarms, horns, sirens, or healthcare instructions -not being able to smell gas leaks or smoke -loss of taste may cause eating of tainted or unsafe food
route of administration
-the rate of absorption depends on the route the drug is taken -oral preparations usually take the longest to be absorbed -IM and SubQ are more rapid -IV drugs have the fastest rate of absorption
Role as a patient caregiver
4 primary objectives: 1) promote health 2) prevent illness 3) restore health 4) facilitate coping
How big should the blood pressure cuff be?
40% of the arm circumference where it is wrapped
Safe use of home oxygen equipment includes keeping the unit at least ___ feet away from a heat source.
8
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units
A) 11,000 units
Based on the documentation in the medical record, which action should the nurse implement next? A. Give the rubella vaccine subcutaneously B. Observe the mother breastfeeding her infant C. Call the nursery for the infant's blodd type result D. Administer Vicodin one tablet for pain
A. Give the rubella vaccine subcutaneously
Ethnocentrism
Belief that one's ideas, beliefs, and practice are the best or superior
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie.
C) Skim milk, turkey salad, roll, and vanilla ice cream Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium
Which interventions should the PN implement to reduce the incidence of UTI in a client with an indwelling catheter?
Cleanse the peri area with soap and water BID and PRN
Transfer of heat from the body directly to another surface (when the body is immersed in water)
Conduction
lotion
Drug particles in a solution for topical use
Recognized authority by a professional group Regulation by the medical industry Ongoing research
Nursing is recognized increasingly as a profession based on which defining criteria? Select all that apply.
Where should you hold the cane?
On the strong side of the body
How often should a patient change the ostomy appliance?
Once or twice a week
What is beneficence?
Promoting the well being of individuals and the public (do good) Ex- doing dental screenings
central nervous system
seizures due to overstimulation of CNS
Plantiffs
"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. Those bringing the charges against Jean are called:
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.
(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.
(C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem. Correct Answer: C
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client. Correct Answer: D
early morning care
-assist patient with toileting -provide comfort measures to refresh patient to prepare for the day -wash face and hands -provide mouth care
incubation period
-organisms growing and multiplying
A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
1. A 60-year-old male client with rhinitis 2. A 24-year old male with lower back injury 3. 10-year-old female client with a urinary track infection 4. A 45-year-old female client with a history of migraine headaches
The client arrives in the emergency department complaining of chest pain that began four hours ago. A troponin T blood specimen is obtain, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates:
1. A normal level 2. A low value that indicates possible gastritis 3. A level that indicates a myocardial infarction 4. A level that indicates the presence of possible Angina
The client with atrial fibrillation was receiving maintenance therapy with warfarin sodium has a prothrombin time of 30 seconds. The nurse anticipate step which of the following will be prescribed?
1. Adding a dose of heparin 2. Holding the next dose of warfarin sodium 3. Increasing the next dose of warfarin sodium 4. Administering the next dose of warfarin sodium
A nurse is reviewing the health records of assigned client. The nurse plan care knowing that which client is at the lowest risk for development of third spacing?
1. The client with sepsis 2. Client was cirrhosis 3. client with renal failure 4. Client with diabetes mellitus
A nurse takes a client temperature for giving a blood transfusion. The temperature is 100 Fahrenheit. The nurse reports the finding to the registered nurse anticipation that which of the following actions will take place?
1. The transfusion will begin as prescribed 2. The blood will be held, and the health care provider will be notified 3. The transmission will begin after the administration of an antihistamine 4. The transfusion will begin at the administration of 600 mg Acetaminophen. (Tylenol)
What is the maximum time of consecutive hours you can use restraints?
24 hours
The nurse should use a __ to ___ mL syringe to irrigate a wound.
30-60
A client is receiving 0.5 grams of a prescription medication that is dispensed as 500 mg/5mL. How many ml should the PN administer? (enter the numeric value only. If rounding is required, round to the nearest tenth.)
5
How far should you move the cane in front of you when walking?
6-10 inches
The nurse observes that there are secretions in the air vent lumen of client's double lumen Nasogastric tube (NGT). Which action should the nurse implement? A. Instill 20 mL of air into the second lumen B. Irrigate the primary lumen with 20 mL of saline C. Place the client in a high Fowler's position D. Turn the suction device to continous suction
A. Instill 20 mL of air into the second lumen
Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? A. Application of topical antibacterial cream B. Use of careful hand washing technique C. Administration of plasma expanders D. Limiting visitors to the burned client.
B. Use of careful hand washing technique
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.
Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). Correct Answer: A
The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area. A. Duodenum B. Gastric Pylorus C. Liver D. Spleen
C. Liver
Risks for the School-Age Child
Different environments outside of the home, such as school, school transportation, after school activities, etc. Strangers, sports activities, bicycle related injuries.
The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells.
Diffusion
_________ is the transportation of medications to sites of action by bodily fluids.
Distribution
The PN is obtaining the vital signs for a client who has a urinary tract infection with MRSA. How should the PN proceed?
Don a gown and gloves before entering the room.
Which food should the PN recommend to a client as a source of complete protein?
Eggs
A male Native American client with TB is visiting a health care clinic for a follow up treatment. During the interview, the PN notices that the client keeps his eyes on the flow and does make eye contact. How should the PN interprets this client's behavior?
His culture finds sustained eye contact rude or disrespectful
Hydrogel (Aquasorb)
Hydrogel (Aquasorb) - Composition is mostly water; gels after contact with exudate, promoting autolytic debridement and cooling
Stage 2 pressure ulcer
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.
What position allows for maximum expansion of the lungs?
Semi-Fowler's
What is veracity?
Telling the truth and expecting it of others (trustfulness; integrity, determination)
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.
The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct Answer: B
What happens during ventricular diastole?
The ventricles relax and there is minimal pressure on the arteries
0.24 seconds Explanation: In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.
Which PR interval presents a first-degree heart block?
Cancer pain
can be acute and/or chronic, sometimes nociceptive and/or neuropathic; usually due to tumor progression and its related pathological process, invasive procedures, toxicities or treatments, infection , and physical limitation--at actual site or referred
How should the nurse clean a wound to prevent introduction of microorganisms from the outer skin surface?
from center outwards
4+ pulse means
full volume, bounding
What is medicare part A?
hospital and durable medical equipment insurance
What is a premium?
how much employee is paying for insurance plan
The nurse should consider the AP's previous training in order to determine _______.
how much supervision they require
Is hypertension or hypotension a sign that indicates that a pt has decreased oxygen to the tissues?
hypertension
causes of dehydration
hyperventilation, diabetic ketoacidosis, enternal feeding without sufficient water intake.
The nurse should preoxygenate the pt with 100% O2 before suctioning a tracheostomy to prevent ____.
hypoxemia
Why should you not lay a pt with an NG tube down in a supine position?
increases risk of aspiration
2 months
leifts head off mattress. holds hands in an open position
When should suction be applied in the NG tube?
once it's inserted and the position is verified
What is theory y?
people want to find meaning in their work and will contribute in positive ways if the work is well designed
How do you measure diffusion?
pulse ox
lithotomy position
supine, feet in stirrups
What is methadone?
synthetic opiate that blocks craving for and effect of heroin
The ultimate authority of nursing practice is . . .
the state board of nursing
type of medication
there are special syringes for certain uses. ex. insulin syringe is only used for insulin
Rephrasing rather than repeating misunderstood information promotes ______.
understanding
11 months
walks while holding on to something. can place objects in a container
15 months
walks without help. creeps up stairs. uses cup well. builds tower of two blocks
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.
(C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct Answer: C
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180
(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D
Ethical conduct
* Begins in nursing school * High-quality care based on professional standards of ethics * Nurses identify and become familiar with bioethical standards for professional nursing conduct
Values
* Beliefs about the worth of something * Formed during a lifetime * Environment * Family * Culture
Types of ethics
* Bioethics * Clinical * Nursing
Culturally competent nursing care
* Care is planned and given in a way that is sensitive to needs * Healthcare system is a culture with customs, rules, values, and a language of its own * Cultural assessment * Guidelines for nursing care
Accreditation
* Maintain minimum standards * State Board of Nursing
Health maintenance
* Nursing interventions that are focused on maintaining the patient's level of health
Assessment/teaching for aging adult
* Nutrition: less food, more often, low salt/fat/sugar * Regular exercise * Encourage independence: teach proper use of canes and walkers * Encourage regular socialization * Medications: teach proper use and correct dosage * Protect from injury: falls, hypothermia, assess living situation and remove throw rugs, place furniture safely, look at walking shoes
Professionalism
* Practice within the ethical and legal framework of the nursing profession * Identify individual learning goals to promote learning for personal and professional development in a changing healthcare environment
Habits
* Use of a systematic approach and problem-solving methodology
Professional values
* Value clarification: - Process of understanding your own values and value system - Involves choosing alternatives - Prize which value involve feeling pride and happiness - Acting by combining choice into one's behavior
Exercise and Musculoskeletal system
-increase muscle efficiency (strength) and flexibility -increased coordination -reduced bone loss -increased efficiency of nerve impulse transmission
Exercise and Cardiovascular system
-increased efficiency of the heart -decreased HR and BP -increased blood flow to all body parts -improved venous return -increased circulating fibirnolysin (substance that breaks up small clots)
Exercise and psychosocial outlook
-increased energy, vitality and general well being -improved sleep -improved appearance -improved self-concept -increased positive health behaviors
exercise and metabolic processes
-increased triglyceride breakdown -increased gastric motility -increased production of body heat
parts of the medication order
-patients name -date and time order is written -name of drug to be administered -dosage of drug -route by which drug is to be administered -frequency of administration -signature of the person writing the order
general assessment of pain
-patients verbalization and description -duration -location -quantity/intensity -quality -chronology -aggravating and alleviating factors -physiologic indicators -behavioral responses -effects of pain on activities and lifestyle
common portals of exit
-respiratory -GI -Genitourinary tracts -breaks in skin -blood and tissue
developing listening skills
-sit when communicating with a patient -be alert and relaxed and take your time -keep the conversation as natural as possible -maintain eye contact if appropriate -use appropriate facial expressions and body gestures -think before responding the patient -do not pretend to listen -listen for themes in the patient's comments -use silence, therapeutic touch, and humor appropriately *listening attentively is key to productive communication*
Surgical asepsis
-sterile technique -used in operating room, labor and delivery areas and certain diagnostic testing areas -can be performed at patient beside with insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine
medication supply systems
-stock supply -individual unit dose supply -medication cart -computerized automated dispensing system -bar code-enabled medication cart (BCMA)
psychosocial health state and safety
-stressful situations tend to narrow a persons attention span and make the person more prone to accidents -stress can occur over a long period of time but effects tend to be more devastating persons later years (less adaptive and coping capacity) -depression may result in confusion and disorientation, accompanied by reduced awareness or concern about environmental hazards
Safety Considerations for Adolescents
-teach safe driving skills -teach avoidance or tobacco and alcohol -emphasize gun safety -follow healthy lifestyle -teach about sexuality, STIs, and birth control -get physical examination before participating in sports -teach risk of infection with body piercing and tattoos -teach about guns and violence -discuss dangers associated with the internet Why? -this is a critical period in growth and development -during this time the mind has a great ability to acquire and use knowledge -teens peer group is a greater influence than parents
powered full-body lift
-used for patients who are uncooperative with an inability to bear weight
medical asepsis at home
-wash hands before preparing or eating food -prepare foods at high enough temperatures -use care with cutting boards and utensils -keep food refrigerated -wash raw fruits and veggies -use pasteurized milk and fruit juices -wash hands after using bathroom -use individual care items
What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving
1 The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.
A nurse obtains a prescription from a physician to restrain hey client using a jacket (security ) restraint and instructs the nursing assistant to apply The restraint to the client. Which of the following observation if made by the nurse would indicate, The inappropriate application of the restraint?
1. A safety knot in the restraint strap 2. The restraints straps are safely secured to the side rail 3. The jacket restraints jacket does not tightened when forest is applied against to it 4. The jacket restraint is secure and two fingers can easily slide between The restraint strength and the client skin
A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurses told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?
1. A task approach method to use to provide care to clients 2. Managed-care concepts and tools are used when providing client care 3. Nursing staff are led by a nurse when providing care to a group of clients 4. A single register nurse is responsible for providing nursing care to a group of clients
A nurse enters a clients room and finds that the wastebasket is on fire. A nursing meet me assisted client out of the room. The nursing next action would be to :
1. Call for help 2. Extinguish the fire 3. Activate the fire alarm 4. Find the fire by closing in room door
A nurses preparing an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing , The tubing drops and hits the top of the medication cart. The nurse should plan to do which of the following?
1. Change the IV tubing 2. Wipe the tubing with Betadine 3. Scrub the tubing with alcohol swabs 4. Scrub the tubing before attaching it to the IV bag
A nurse reviews electrolyte values and notes a sodium level of 130. The nurse understands that this sodium level would be noted in a client with which condition?
1. Client with watery diarrhea 2. Client with diabetes insipidus 3. Client with inadequate daily water intake 4. Client with the syndrome of inappropriate secretion of anti diuretic hormone
Hey Nurse is making a worksheet and listing The tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client Who is receiving fluid replacement therapy at least every:
1. One hour 2. Two hours 3. Three hours 4. Four hours
A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism
3 When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.
During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery? A. "Deep breathing exercises using spirometer will help prevent postoperative complications." B. "failure to keep your lungs working may result in pneumonia and death." C. "Incentive spirometry is uncomfortable but necessary for your postoperative care." D. "You will use the spirometer for the first postoperative day only."
A. "Deep breathing exercises using spirometer will help prevent postoperative complications."
An elderly client is admitted for evaluation of Alzheimer's disease. At 2AM, the nurse finds the client tyring to open the emergency door. What is the most appropriate response for the nurse to make in this situation? A. "This is the emergency door. Are you looking for the bathroom?" B. "You look confused. Would you like to talk about your feelings?" C. "Let's go back to your room. Your doctor does not want you to be walking alone." D. "You want to go outside at this time of night? It's dangerous out there."
A. "This is the emergency door. Are you looking for the bathroom?"
A 60 year-old client with cancer of the liver is in Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" B. "The nurses have not been able to arouse the client and the healthcare provider knows the outcome." C. "You need to discuss the condition with the charge nurse in a family conference." D. "The client's condition is extremely critical. Has your family made funeral arrangements?"
A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours"
Middle adulthood (40-65): generation vs. stagnation
* Awareness of aging process with some increase of health problems * Maturation and acceptance of family roles, careers, economic responsibilities * Some crises: aging, death of loved ones
Certification
"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. Jean's attorney was careful to explain in her defense that Jean had specialty knowledge, experience, and clinical judgment and had met certain criteria established by a nongovernmental association, as a result of which she was granted recognition in a specified practice area. What is this sort of credential called?
Hildegard Peplau
* 1952 * "mother of psychiatric nursing" * Was a true pioneer in the development of the theory and practice of psychiatric and mental health nursing * Interpersonal relationships theory
Patient's Bill of Rights
* 1972 (revised in 2003 as the Patient Care Partnership) * Rights and responsibilities of the patient while receiving care in the hospital
Madeline Leininger
* 1978 * Transcultural Nursing
Patricia Benner
* 1989 * Novice to Expert * Stages of a clinical competence
Nurses advocacy
* Advocacy: protection and support of another's rights * Represent patients * Facilitate patient's decision making
Angles of Insertion for Various Injections
--IM 72, 90°. --SQ 45, 90°. --Intradermal 5-15°.
drug interactions
-adverse effect -occur when one drug is affected in some way by another drug, a food, or another substance that is taken at the same time
transfer chairs
-chairs that transfer to stretchers -used for patients who are uncooperative, with inability to bear weight
therapeutic range
-concentration of drug in the blood serum that produces the desired effect with out causing toxicity
categories of pain
-duration (acute/chronic) -localization/location -Etiology
And adult male client admitted with dehydration has received fluid volume replacement. The nurse determines that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which of the following values in the normal range?
1. 34% 2. 39% 3. 48% 4. 56%
A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands The diet if the client states that A food item is avoid is:
1. Apples 2. Cheese 3. Oranges 4. Skim milk
A nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse tells the client that which food item contains the least amount of calcium?
1. Milk 2. Butter 3. Spinach 4. Collard Greens
What is bureacratic leadership?
driven by policy and procedures
What are the four blended competencies of nursing?
1. cognitive 2. technical 3. interpersonal 4. ethical/legal
How much urine output is the bare minimum and the physician should be called for?
30ml/hr for 2 consecutive hours
Hypothermia is a body temperature below
35 degrees celsius
What should the nurse adjust the suction pressure to before suctioning a tracheostomy?
80 to 120 mm Hg
How big should a blood pressure cuff be to obtain an accurate reading?
80% of the pt's arm circumference
Medication Administration: Drug Assessment
A complete, legal order: -Appropriateness (rationale for use of this drug for this patient) -Action, dosage, route, adverse effects -Contraindications, interactions -Other data: lab results, vital signs, etc
objective data
observations or measurements of a client's health status
nursing action for hypoxia
oxygen therapy, incentive spirometer, diaphragmatic breathing
Respiratory Alkalosis
pH Above 7.45 PaCO2 Below 35 HCO3 Normal Common Example: Hyperventilation
Respiratory Acidosis
pH Below 7.35 PaCO2 Above 45 HCO3 Normal Common Example: Hypoventilation
Visceral Pain
Arises from viscera, such as the GI tract and pancreas; Described as squeezing, cramping pain, shooting; May be due to obstruction of hollow viscous, which causes the cramping and poorly localized pain
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Autopsy of the body is prohibited. B) Blood transfusions are forbidden. C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed
B) Blood transfusions are forbidden Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B).
A client returns to the unit following a cardiac catheterization with a Femoral artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return? A. Pupil responses to light B. Pedal pulses C. Respiratory rate D. Peripheral mobility
B. Pedal pulses
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private.
C) Acknowledge the client's distress and tell her it is all right to cry Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings
What does Disulfiram cause?
unpleasant physical effects if alcohol is present in the body
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified
C) Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues
The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site? A. Umbilical area of the abdomen B. Antecubital fossae of the arm C. Chest wall below the clavicle D. Dorsal surface of the hand
C. Chest wall below the clavicle
Health
Defined by the World Health Organization, one's health includes physical, social, and mental components and is not merely the absence of disease or infirmity
Endogenous Infection
Occurs when part of the patient's flora becomes altered and an overgrowth results. (staphylococci, enterococci, yeasts, and streptococci) Often happens when a patient receives broad-spectrum antibiotics that alter the normal floras.
When are medications are given with palliative care?
Given for air hunger, anxiety, and pain
injectable
Given via a needle
When can the law require an autopsy?
In a homicide, suicide, accidental death, or within 24 hours of hospital admission.
3+ pulse means
Increased, strong
Situational loss
This is any unanticipated loss caused by an external event.
The physician
The patient in Room 410 has a BP of 188/126. Who you gonna call...
What's the ANA's definition of nursing?
The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
Utilitarian =
The rightness or wrongness of an action depends on the consequences of the action.
Atelectasis
collapse of alveoli which prevents normal exchange of oxygen and carbon dioxide
Which intervention provides confirmation of NGT placement before NGT feedings are started?
X-ray of the abdomen
PRN
as needed
What is buprenorphine?
blocks the signs and symptoms of opioid withdrawal
Cyanosis
blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries-late sign of hypoxia
presbycusis
decreased ability to hear high-pitched sounds
severe anxiety symptoms
dizziness, nausea
positive trousseau's sign
hand/finger spasms with sustained blood pressure cuff inflation
With glaucoma you lose what type of vision?
loss of peripheral vision
What is used wen the client is moving from one health care area to another?
transfer document
The Joint Commission 2011 National Patient Safety Goals for Hospitals
• Identify patients correctly. • Use at least two patient identifiers. • Eliminate transfusion errors. • Improve staff communication. • Report important test results in a timely manner. • Use medicines safely. • Label medications. • Reduce harm to patients who take anticoagulation therapy. • Reduce the risk of health care-associated infections. • Meet hand hygiene guidelines. • Prevent multidrug-resistant organism infections. • Prevent central line-associated bloodstream infections. • Use safe practices to treat the part of the body where surgery was performed. • Check patient medicines. • Identify current medicines and make sure that it is okay for patients to take any new medicines with current medicines. • Give a list of patient's medicines to the next provider before discharge. • Give a list of patient's medicines to patient and family before discharge; explain the list. • Identify patient safety risks. • Identify individuals at risk for suicide.
Which action should the PN follow when applying an elasticize bandage to a client's leg?
Overlap turns of the bandage equally
Principles of Oxygen Therapy
Oxygen should be treated as a drug Expensive Side Effects Safety issues Verify 6 Rights of medication
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." Explanation: The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers
P-R interval
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint. D) Change in the circumference of the joint in centimeters
C) Degree of flexion and extension of the client's knee joint The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).
The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers.
PR Interval
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.
C) Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. (A,B, and D)
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C) Examining a chest x-ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.
C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider.
C) Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation
Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first.
C) Keep gloved hands above the elbows Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).
The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. Arrage the routes of administration in the order from fastest to slowest rate of absorption. Subcutaenous Intravenous Intramuscular Sublingual Oral
Intravenous, sublingual, intramuscular, subcutaneous, oral.
Infection
Involves invasion of tissue or cells by microorganisms (bacteria, fungi, or viruses) Always has inflammation present Often reveals altered lab values ( i.e. WBCs, positive cultures)
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment. B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices.
C) Many complimentary healing practices can be used in conjunction with conventional practices Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).
The practical nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase granulation tissue will develop within 2 weeks," which intervention should the PN implement.?
Irrigation of the wound with sterile normal saline
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal.
C) Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level.
C) Reposition in a Sim's position with the client's weight on the anterior ilium The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned
Medication Administration: Patient Assessment
Identify high-risk patients: -Liver and kidney impairment -Genetic factors -Drug allergies -Pregnancy -Elderly and pediatrics -Tools: patient history, physical exam, and lab results
What is significant, and considered orthostatic hypotension?
If the systolic blood pressure decreases more than 20mmHG and/or the diastolic pressure decreases more than 10mmHg with a 10-20% increase in heart rate.
safe administration of medication
Know: -the drugs being administered -drug names (generic and brand) -preparations for administration -classification of the drug -dosage -desired and adverse effects -physiologic factors that affect drug action
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A) asks relevant questions regarding the dressing change. B) states he will be able to complete the wound care regimen. C) demonstrates the wound care procedure correctly. D) has all the necessary supplies for wound care.
C) demonstrates the wound care procedure correctly A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care
Ultra Lente, Glargine (LANTUS) Onset: 1 hr Duration: 24 hrs NO PEAK
Long Acting
With Macular Degeneration you lose what type of vision?
Loss of central vision
A 6-month old male with Bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates the nurse that he is experiencing Respiratory Distress? A. Respiratory of 62 breaths/minute B. Abdominal breathing C. A high-pitched cry D. Dry flushed skin
C. A high-pitched cry
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified? A. Temperature of 100.8F B. A pulse rate of 150 beats per minute C. A respiratory rate of 10 breaths per minute D. A blood pressure of 180/110
C. A respiratory rate of 10 breaths per minute
A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take? A. Contact the pharmacy and request the prescribed form of aspirin B. Instruct the client about the effects when given the medication C. Administer the aspirin with a full glass of water or a small snack D. Withhold the aspirin until consulting with the healthcare provider
C. Administer the aspirin with a full glass of water or a small snack
A child with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage treatments? A. Before postural drainage B. During postural drainage C. After postural drainage D. Between treatements
C. After postural drainage
A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrghaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what action? A. Using a tight seal around the mouth piece B. Exhaling slowly after two seconds C. Blowing forcefully into the mouthpiece D. Sitting upright during treatment
C. Blowing forcefully into the mouthpiece
A female client with no family history of Breast Cancer (BA) asks the nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question? A. Current age B. Breast size C. Breastfeeding history D. Menopausal status
C. Breastfeeding history
The first day after a cesarean section (C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take? A. Insert an indwelling catheter to empty the bladder and contract the fundus B. Return the client to bed and maitain bed rest until the lochial flow slows C. Check fundal consistency and continue to monitor the lochial flow amount D. Massage the fundus and avoid direct pressure on the cesarean incision.
C. Check fundal consistency and continue to monitor the lochial flow amount
The nurse assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepear for which treatment? A. Heat lamp three times per day B. Insertion of vaginal packing C. Cold packs to the perineum D. Operative excission of the hematomas
C. Cold packs to the perineum
In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? A. Recheck the radial pulse in thirty minutes B. Palpate the radial pulse for thiry seconds and double the rate C. Count the apical pulse rate for sixty seconds D. Compare the radial pulse rate bilaterally and record the higher rate.
C. Count the apical pulse rate for sixty seconds
The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage? A. Place a 4X4 wick in the stoma opening B. Apply a layer of zinc oxide ointment to the perimeter of the stoma C. Cut the bag opening to the measurement of the stoma size D. Administer a PRN antidiarrheal agent
C. Cut the bag opening to the measurement of the stoma size
A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? A. Assess site of sting and remove stinger if present B. Perform mini-mental status exam to assess level of consciousness C. Determine respiratory status and apply a pulse oximeter D. Attach electrodes to monitor cardiac rhythm
C. Determine respiratory status and apply a pulse oximeter
The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit? A. Edemetous lower extremities and an increased temperature B. A decreased temperature and increased blood pressure C. Dry skin and an increased heart rate D. Diaphoresis and hypertension
C. Dry skin and an increased heart rate
The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take? A. Advsie the wife to shave against the hair growth B. Teach the wife to keep the skin loose to avoid cuts C. Encourage the wife to continue shaving her husband D. Demonstrate the correct procedure to the wife
C. Encourage the wife to continue shaving her husband
A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? A. Offer to call the social worker to discuss the possiblity of abortion B. Reassure the client that the infertility specialist can help C. Express sorrow for the client's grief and offer to sit with her D. Chart the vital signs and amount of vaginal bleeding
C. Express sorrow for the client's grief and offer to sit with her
On a short-staffed unit a long-term care facility, it is important that the nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first? A. Dyspnea who uses oxygen continously B. Straight catheterization to be performed q6h C. Frequent episidoes of fecal incontinence D. Bolus feeding via PEG tube to be performed q4h
C. Frequent episidoes of fecal incontinence
The nurse is caring for a client who had a total Laryngectomy, Left Radical Neck Dissection, and tracheostomy. The client is receiving Nasogastric (NG) tube feedings via an enteral pump. Today the rate of the feeding was increased from 50mL/hr to 75mL/hr. What parameter should the nurse evaluate the client's tolerance to the rate of feeding? A. Bowel sounds B. Urinary and stool outputs C. Gastric residual volumes D. Daily weight
C. Gastric residual volumes
An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and then tells the nurse, "I just don't feel right" Which initial action should the nurse take? A. Assess temperature B. Evaluate deep tendon reflexes C. Give 4 ounces of apple juice D. Administer glucagon 0.5mg IM
C. Give 4 ounces of apple juice
4 hours after administration of 20U of regular insulin, the client becomes shake and diaphoretic. What action should the nurse take? A. Encourage the client to excercise B. Administer a PRN dose of 10U of regular insulin C. Give the client crackers and milk D. Record the client's reaction on the diabetic flow sheet
C. Give the client crackers and milk
The nurse is caring for a group of clients on a postpartum unit. After shift report, which client should the nurse assess first? A. Gravida 6 Para 5 who delivered vaginally 24 hours ago B. Gravida 1 Para 0 who is not having contractions C. Gravida 3 Para 3 who delivereed vaginally 2 hours ago D. Gravide 1 Para 2 who is preparing for dischage
C. Gravida 3 Para 3 who delivereed vaginally 2 hours ago
Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately? A. My left foot is so painful B. My incision is so dry C. I've been feeling so light headed D. I'm tired of turning so much
C. I've been feeling so light headed
In obtaining an orthostatic vital sign measurement, what action should the nurse take first? A. Count the client's radial pulse B. Apply a blood pressure cuff C. Instruct the client to lie supine D. Assist the client to stand upright
C. Instruct the client to lie supine
The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news? A. Refer the family to a support group to find answers to their questions B. Reinforce the stages of the grieving process C. Listen to the family's reactions and reflect and their fears and concerns D. Transfer the child to a private room
C. Listen to the family's reactions and reflect and their fears and concerns
A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period? A. Diaper weights and urin specific gravity B. Gastronomy feedings in supine position C. Nipple feedings with glucose water D. Gavage feedings with 15mL of formula
C. Nipple feedings with glucose water
The nurse reviewes the laboratory results of a client whose serum pH is 7.38 on the pH scale what does this value imply about the clients homeostasis A. Alkalosis B. Acidosis C. Normal serum PH D. Incompatible with life
C. Normal serum PH
The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client? A. Nurse who contracts child protective services to report a mother's decision to refuse vaccination for her firstborn infant B. Nurse refusing to care for a convicted rapist stating that personal discomfort would inhibit provision of quality of care C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds D. Nurse sharing information about life after death with a grievin family who just lost a loved one
C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds
Which nursing activity is within the scope of practice for the practical nurse? A. Complete an admission assessment in the normal newborn nursery. B. Discontinue a central venous catheter that has become dislodged C. Observe a client rotate the subcutaneous site for an insulin pump D. Monitor a continous narcotic epidural for a postoperative client
C. Observe a client rotate the subcutaneous site for an insulin pump
The nurse assigns an unliscensed assistive personnel (UAP) to feed a client who is at risk for aspirations. To ensure that the task is safely delegated what action should the nurse implement? A. Inform the UAP that the suction is available at the bedside B. Instruct the UAP to notify the PN if the client begins to choke C. Observe the UAP's ability to implement precautions during feed D. Ask the UAP about previous experience performing this skil
C. Observe the UAP's ability to implement precautions during feed
What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space? A. Filtration B. Diffusion C. Osmosis D. Active transport
C. Osmosis
A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly women. A. Urinary retention resulting in renal calculi formation B. Failing eyesight resulting in an unsafe environment C. Osteoporosis resulting from hormonal changes D. Transient ischemic attacks (TIAs) which impair mental activity
C. Osteoporosis resulting from hormonal changes
Following an open reduction of the tibian, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement? A. Assess the client's hemoglobin to determine if the client is in shock B. Call the surgeon and prepare to take the client back to the operating room C. Outline the area with ink and check it q15 minutes to see if the area has increased D. No action is required since postoperative bleeding can be expected
C. Outline the area with ink and check it q15 minutes to see if the area has increased
A 75-year-old male client with Alzheimer's Disease (AD) is admitted to an extended care facility. What intervention should the nurse include into his client's Nursing care plan? A. Describe the activities available to the residents and encourage him to choose the ones he prefers B. Introduce the client to the Nursing staff and the residents as soon as possible C. Plan to have the same Nursing staff provide care for the client whenever possible D. Encourage the client to remain on the unit for 3 weeks until he is oriented to his new surroundings
C. Plan to have the same Nursing staff provide care for the client whenever possible
The nurse is preparing to insert an indwelling catheter for an 89-year-old client who has severe contractures of both lower extremities. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. What action should the nurse take? A. Report to the charge nurse that the client cannot cooperate for the insertion B. Recruit two UAPs to hold the legs apart while the catheter is inserted C. Position laterally for posterior access in visualizing the meatus for insertion D. Pre-medicate the client with a narcotic analgesic to relax the skeletal muscles
C. Position laterally for posterior access in visualizing the meatus for insertion
While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement? A. Swab the oral cavity with a washcloth B. Use oral swabs with normal saline C. Provide a Yankauer tip for oral suction D. Support the head with a small pillow
C. Provide a Yankauer tip for oral suction
The nurse is reviewing instructions for the use of pilocarpine eye drops with a client who has Glaucoma. The client states, "I should have these drops to anesthetize my eye if I experience pain" What action should the nurse implement? A. Explain to the client the eye drops do provide pain relief, but do not anesthetize the eyes B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common C. Re-teach the client about the action of the eye drops to decrease pressure in the eye D. Document in the chart that the client understands the action and use the eye drops
C. Re-teach the client about the action of the eye drops to decrease pressure in the eye
The nurse assess a client receiving a hypertonic full strength tube feeding that is infusing continous at 50 mL/hr. Which finding is most important for the nurse to reprot to the charge nurse? A. Dry mucous membranes B. Gastric residual of 50 mL C. Report of increased hunger D. Hyperactive bowel sounds
C. Report of increased hunger
A client is having Radical Masectormy. What is the position of choice during the immediate postoperative period? A. Side-lying on the operative side with the bed flat B. Supine with the arm on the operative side in a dependant position C. Semi-Fowler's position with the arm on the operative side elevated D. Sim's position with the arm on the operative side in a dependant position
C. Semi-Fowler's position with the arm on the operative side elevated
The nurse explains the 2-week dosage prescription of prednison (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule? A. Decrease dosage daily as prescribed B. Monitor oral temperature daily C. Take the prednison with meals D. Return for blood glucose monitoring in one week
C. Take the prednison with meals
In preparing a client for a lumbar puncture, what action should the nurse implement? A. Assist the client to the bathroom to void B. Apply a pulse oximeter to the client's finger C. Teach the client to cough and deep breathing exercises D. Ensure that the client has been NPO for six hours.
C. Teach the client to cough and deep breathing exercises
An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? A. The physical therapis will instruct the client in the use of a walker B. The nurse will place a gait belt on the client prior to ambulation C. The client will ambulate with assistance q4h D. The client will use self-affirmation statements to decrease fear
C. The client will ambulate with assistance q4h
What length of blood pressure cuff should be the nurse use when obtaining a client's blood pressure? A. A cuff that is no longer than the circumference of the extremity should be used B. The lenght of the blood pressure cuff does not make a difference C. The cuff and its bladder should be nearly encircled the the extremity's circumference D. At least two-thirs the circumference of the extremity should be coverered
C. The cuff and its bladder should be nearly encircled the the extremity's circumference
The nurse is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? A. Abnormal skin color changes in a client with dark skin cannot be determined B. Blanching the soles of the feet in a client with dark skin reveals cyanosis C. The lips and mucus membranes of a client with dark skin are dusky in color D. Cyanosis in a client with dark skin is seen in the sclera
C. The lips and mucus membranes of a client with dark skin are dusky in color
The nurse is working on the postpartum unit and is assisting a new mother with her newborn's diaper change. The mother states that the infant fed well and completed the whole bottle of formula. What action should the nurse implement first when the infant begins to spit up during the diaper change? A. Bubble or burp the infant by patting the infant's back B. Encourage the mother to avoid over feeding the infant C. Turn the newborn and bulb suction the mouth and nose D. Wipe away the secretions and finish the diaper change
C. Turn the newborn and bulb suction the mouth and nose
A female client complains to the nurse about being admitted to a semi-private room and expresses her displeasure because she requested a private room prior to admission. What response is best for the nurse to provide this client? A. Room assignments are based on client's acuity level, not necessarily by request B. I will place your name on the room request list for the next available private room C. Your healthcare provider must provide a written request to get you a private room D. There are no private rooms available, so you will have to stay here for the time being.
C. Your healthcare provider must provide a written request to get you a private room
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first. Correct Answer: B
Which action by the PN demonstrates the value of dignity in client care?
Closes the doors and covers the client during a bath.
A client whose diet is low in fiber is at risk for which condition?
Colon cancer
Exogenous Infection
Comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Asperigillus. Do not exist as normal floras.
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.
Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice. Correct Answer: D
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.
Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D). Correct Answer: C
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes. Correct Answer: C
The PN hears breath sounds that are short, popping, and discontinuous on inspiration when auscultations a clients lungs. Which description should the PN document in the clients record?
Crackles auscultated
Which findings indicates to the PN that an older client who is receiving intravenous therapy is experiencing fluid overload?
Crackles in the lungs
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A) 31 gtt/min. B) 62 gtt/min. C) 93 gtt/min. D) 124 gtt/min
D) 124 gtt/min
The nurse was the mother who cared for her family during sickness by using herbal remedies.
In early civilizations, the theory of animism attempted to explain the mysterious changes occurring in bodily functions. Which statement describes a component of the development of nursing that occurred in this era?
State nurse practice acts
In the United States, the practice of nursing is regulated by which of the following?
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.
D) Ensure the accuracy of the blood type match All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition.
D) Hot remedies restore balance after surgery, which is considered a "cold" condition Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice.
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed
D) Immediately after the assessments are completed Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics.
Battery
"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. If review of this patient's record revealed that she had never consented to the eye surgery, of which intentional tort might the surgeon have been guilty?
The nurse had a duty to monitor the patient's vital signs, failed to do so, the patient died, and it was Jean's failure to do her duty that caused the patient's death.
"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. What must be established to prove that malpractice or negligence has occurred in this case?
"I'm sorry, but I can't talk with you. You'll have to contact my attorney."
"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. When the attorney representing the patient's family calls Jean and asks to talk with her about the case so that he can better understand her actions, how should Jean respond?
What is providing "pat" answers?
"Oh everyone feels that way." " Oh everyone goes through this."
What is provision 1.5?
"The principle of respect for persons extends to all individuals with whom the nurse interacts."
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.
(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct Answer: D
Sr. Callista Roy
* 1974 * Adaptation Model * States that the individual is a set of interrelated systems that strive for balance
Patient's rights
* Able to see and copy their own medical record * Update their health record * Choose how to receive health information * Right to accurate and easy to understand information * Right to choose healthcare providers * Right to respectful care * Right to participate in treatment options * Right to talk privately and have your information protected * Righ to fair, fast, and objective review of any complaint that you have against caregivers * Right to emergency services
Code of ethics
* Agency policies, and State and Federal privacy legislation dictate how patient information can be communicated (verbally and in writing) * While most nurses are staunch advocates of a patient's right to privacy and confidentiality, many nurses thoughtlessly violate these rights every day (e.g. talking in elevators) * Change in shift report: avoid gossip
5 professional values identified by the AACN
* Altruism: concern for welfare and well-being of others * Autonomy: right to self-determination; respect patient's right to make decisions * Human dignity : respect for the inherent worth of individuals * Integrity: the quality of being honest and having strong moral principles * Social justice: upholding moral, legal, and humanistic principles
Professional nursing organizations
* American Nurses Association (ANA) * National League for Nursing (NLN) * American Association for Colleges in Nurisng (AACN) * National Student Nurses' Assocation (NSNA)
Principles of growth and development
* Are orderly and sequential as well as continuous and complex * Follow regular and predictable trends * Differentiated and integrated * Different aspects occur at different stages and at different rates, and can be modified * Pace is specific for each person * Physical and psychological skills and maturation vary among people
Principles of bioethics
* Autonomy * Nonmaleficence * Beneficence * Justice * Fidelity
Ethical considerations
* Balance between benefit and harm * Informed consent * Family * Relationships between caregivers and patients * Professionalism * Cost * Culture and spiritual * Power
Normal physiologic changes of older adults
* Balance declines * Decreased ability to maintain homeostasis * Integument: wrinkles and sagging skin, change in pigmentation * Decreased sight and hearing * Decrease in SQ tissue and weight, muscle mass, and strength * Bone demineralization * Joints stiffen * Diminished lung capacity and less effective cough * Decreased blood flow and blood vessel elasticity * Less efficient venous return * Fatty plaque deposits * Heart valves thicken * Decreased GI motility and digestive juices * Ab. muscles weaken * Swallowing reflex less effective * Decreased bladder capacity, muscle tone, and prostate gland enlarges * Decrease in response time, balance, coordination, and learning speed * Sleep time at night shortens * Temp. regulation and pain/pressure perception become less efficient
Jean Watson
* Caritas Process * Promote & restore health, prevent illness, and caring for the sick * Holistic care: promote humanism, health, and quality of life
Collaboration
* Collaborate with the patient, family, and health care team utilizing evidence-based health information/informatics to achieve quality outcomes
Common nursing virtues
* Competence * Compassionate caring * Subordination of self-interest to patient care * Self-effacement * Trustworthiness * Conscientiousness * Intelligence * Practical wisdom * Humility * Courage * Integrity
Theory
* Composed of a group of concepts that describe a pattern of reality * Statement that explains or characterizes a process, an occurence, or an event and is based on observed facts * Arrange a group of related statements or concepts that give meaning to a series of events
Nurses' role in healthcare reform
* Cost containment * Improved access * Increased quality of services * Political action (Nurses day on the hill)
Legal issues
* Credentialing: way professional competence is ensured and maintained - Accreditation - Licensure
Major losses
* Death of loved ones * Relocation * Job loss/retirement * Depression from social isolation
Caring
* Demonstrate an attitude of positive regard, respect for diversity, empathy and integrity when providing relationship centered care
Theories
* Derived through 2 principle methods: deductive reasoning and inductive reasoning
Nurses need to:
* Develop cultural self-awareness * Develop cultural knowledge * Accommodate cultural practices in healthcare * Respect culturally based family roles * Avoid mandating change * Seek cultural assistance
Nursing theories
* Developed to describe, explain, predict, and control * Ultimate goal is to improve patient outcomes
Frameworks for healthcare delivery
* Different methods are used to ensure continuity of care and cost-effective care as a patient moves through the healthcare system * These methods include managed care systems, case management, primary healthcare
Secondary level of prevention
* Early detection * Health maintenance * Early intervention
Theory of psychosocial development
* Erik Erickson * 8 stages from infancy to late adulthood * Each stage has major crisis * Lack of resolution prevents aligning to develop fully * Never too late for resolution of any stage crisis
Bill of Rights for Registered Nurses
* Established due to decreased quality of care caused by inadequate staffing and decreased nurse satisfaction * Improve workplace and ensure nurse ability to provide safe, quality patient care * Empower nurses
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
* Federal mandated organization * Specifies that nursing care data r/t patient assessments, nursing diagnoses or patient needs, nursing interventions, and patient outcomes are permanently integrated into the patient record * Each nurse is expected to practice according to local policies and professional standards
Theories of aging
* Genetic theory of aging: genetics and hereditary * Immunity theory of aging: immune system * Cross-linkage theory: chemical reaction that damages DNA and leads to cell death * Free radical theory: free radicals are formed during cellular metabolism which have an adverse effect on adjacent cells
Primary level of prevention
* Health promotion * Illness prevention
Role of the nurse for the elderly
* Health restoration * Health maintenance * Health promotion * Dying with dignity
Political action for healthcare reform
* Healthcare crisis is a societal problem that needs national political attention for a solution * Nurse advocacy for our patient's well-being is an ethical obligation * Political intervention is the key * Nurses need to use their political muscle & credibility
Critical thinking
* Integrate evidence-based knowledge, clinical reasoning, and the nursing process to formulate safe nursing judgments when providing quality care
Theory of cognitive development
* Jean Piaget * 4 stages of from birth to adolescent * Framework for how children learn rules * Each stage transforms and supersedes the one before * Stages are universal (affects all cultures and people)
Health care delivery: nurses
* Largest employee group in health care * Part of health care team * Practice guided by nursing process
Licensure
* Legal document * Entry level competence * State Board revoke of suspend * NCLEX: National Council Licensure Examination
Risk factors for illness
* Lifestyle * Psychosocial * Environmental * Developmental * Biologic
Practices
* Maintenance of health and prevention of illness
Financial aspects of healthcare
* Medicare: part A (pays for hospitalization), part B (supplemental - can buy additional coverage) * Medicaid: state-distributed federal money * Group plans: HMO (health maintenance organization), PPO (preferred provider organization) * Private insurance * Long term care insurance
AACN
* National voice for baccalaureate and higher degree nursing education programs * The organization's goals focus on establishing quality educational standards; influencing the nursing profession to improve healthcare; and promoting the public support of baccalaureate and graduate education, research, and nursing practice * National accreditation for collegiate nursing programs is provided (based on meeting standards) through this professional nursing organization by the Commision on Collegiate Nursing Education (CCNE)
Professional and legal regulation of nursing practice
* Nurse Practice Act: law affecting nursing practice - Protects the public - Lists violations - Excludes untrained or unlicensed people
Evidence-based practice
* Nursing care provided that is supported by reliable research-based evidence * The use of EBP mandates critical analysis and extensive, systematic reviews of research articles and findings to improve nursing interventions/actions
Health promotion
* Nursing interventions done to promote the level of health the patient is currently experiencing * E.g. immunizations, screenings, teachings
Laws affecting nursing practice
* Occupational safety and health * National practitioner data bank * Reporting obligations * Controlled substances * Discrimination and sexual harassment * Persons with disabilities * Wills * Legal issues r/t dying and death
Myths about older adults
* Old age begins at 65 years * Most older adults live in nursing homes * Most older adults are sick * Old age means mental deterioration * Older adults are not interested in sex * Older adults don't care how they look * Bladder problems are a problem of aging * Older adults do not deserve aggressive treatment for serious illness
Older adult: integrity vs. despair
* Older than 65 years * By 2030, 20% of the population will be older than 65 * Older women outnumber older men * Reminiscence about life events provides a sense of fulfillment and purpose
NLN
* Open to all people interested in nursing, including nurses, non-nurses, and agencies * Established in 1952, its objective is to foster the development and improvement of all nursing services and nursing education
Chronic illness
* Permanent change * Remissions * Exacerbations * Slow onset * Requires education/support for rehabilitation * Leading health problems in the world * e.g. heart & lung conditions, arthritis, diabetes, HIV
Culturally competent care
* Physiological characteristics * Psychological characteristics * Reactions to pain * Mental health * Gender roles * Language and communication * Orientation to space and time * Food and nutrition * Family support * Socioeconomic status
5 major components of growth and development
* Physiological: body function * Cognitive: intelligence, thinking * Psychosocial: emotional, reactions with environment and other people * Moral: sense of right and wrong * Spiritual: religious, sense of correctness with inner self
ANA
* Professional organization for RNs in the US * Founded in the late 1800s * Membership is comprised of the state nurses' associations to which individual nurses belong * Establishes standards of practice, encourages research, and represents nursing for legislative actions
RCTC's core integrating concepts
* Professionalism * Critical thinking * Caring * Collaboration * Nursing interventions
Classification of hospitals
* Public: nonprofit institutions are financed and operated by local, state, or national agencies. Patients admitted may not have insurance so services are provided at no cost or little cost to the patient. Tax revenue of public funds covers the cost * Private: can be for profit or nonprofit, operated by communities, churches, corporations, and charitable organizations * e.g. Mayo is private, nonprofit * e.g. Olmsted is public
NCLEX Analysis
* Questions will have application, analysis, synthesis or evaluation as the level of cognitive ability * You will not get knowledge questions, instead you will get questions that have you apply your knowledge * There is a strategy that can be learned from each question.
Illness
* Response of the person to a pathological problem where level of functioning is changed * Individually defined * Disease: pathologic change in the structure or function of the body or mind
Student Liability
* Responsible for their own acts * Be prepared to know agency policies and procedures
Evidence-based practice
* Review and critique research reports * Identify level and strength of the evidence * Make specific recommendation for practice: validate, change, and examples
Guidelines for Nursing Practice
* Scope and Standards of Practice defines the activities of nurses that are specific and unique to nursing * Standards allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where healthcare is given * Each nurse is accountable for his or her own quality of practice and is responsible for the use of these standards to ensure knowledgeable, safe, and comprehensive nursing care
Trends in healthcare delivery
* Self-care focus * Knowledgeable consumers * Cost containment * Fragmentation of care * Aging & diversity of America * Nursing shortage
Ethinicity
* Sense of identification * Share unique cultural and social beliefs
Theory of psychoanalytic development
* Sigmund Freud * Emphasizes the effect of instinctual human drives on behavior * 4 major components * 5 stages * If not resolution in one stage, fixation follows with arrested development * Ego is defense mechanism
Beliefs
* Standardized definition of health and illness
Factors affecting health in the community
* Support systems * Community health care structure * Environment * Economic resources
Ethics
* Systematic inquiry into principles of right/wrong conduct of virtue/vice and of good/evil as they relate to conduct
Federal & state regulatory agencies
* The Centers for Medicare and Medicaid Services (CMS) * The Joint Commission - National Patient Safety Goals (NPSG) * National Committee for Quality Assurance (NCQA)
Ethical theories: Deontological
* The action is right or wrong and is independent of the consequences
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
* The intent of this initiative is to provide a standardized survey instrument and data collection method to get patients perspective on hospital care * National standard for patient satisfaction * Designed to include public reporting of results
Nursing as a profession
* Uses an organized body of knowledge that is generated from research/theory and provides rationale for our nursing interventions/actions * Uses nursing theory which is self-generated and draws from other disciplines/fields
Ethical theories
* Utilitarian * Deontological
Nursing is recognized as a profession based on
* Well-defined body of specific and unique knowledge * Strong service orientation * Recognized authority by a professional group * Code of ethics * Professional organization that sets standards * Ongoing research * Autonomy
Nursing process and medication administration
*Assessment*: -comprehensive medication history, allergies -Pt's health assessment (vital signs, labs) -ongoing assessments of pts response to medication *Nursing diagnosis* -based on assessment data *Plan of action* *Implementation of plan* *Evaluation of intervention or action taken* -outcomes evaluated to assess if actions were effective -plan of care tailored to the patients needs
Acute Inflammation
*heals in 2-3 wks *no residual damage *neutrophils predominant (Subacute is basically the same but last longer i.e. endocarditis)
objective data
- The "S" and "B" -observable and measurable data obtained through observations, physical examination, and laboratory and diagnostic testing
Surgical Asepsis
-"Sterile" technique. -Eliminates all microorganisms, pathogens, spores. -Requires sterile field and equipment (O.R. and during invasive procedure)
SubQ injection
-45 degrees, 2cc 25g -administered into the adipose tissue layer just below the epidermis and dermis -Sites: outer aspects of the upper arm, abdomen, anterior thigh, upper back, upper ventral or dorsogluteal area
The institute of medicine (IOM)
-A branch of the National Academy of Sciences whose goal is to advance and distribute scientific knowledge with the mission of improving human health -identifies safety as an organizational priority and emphasized that medical errors are more frequently due to system problems rather than human error -recognized need for renewed focus on safety
infectious agents
-Bacteria: most significant and most prevalent in hospital settings -Virus: smallest of all microorganisms -Fungi: plant-like organisms present in air, soil, and water
transmission-based precautions
-CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions Three types: -airborne -droplet -contact
Standard precautions
-CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions -these precautions apply to blood, all body fluids, secretions, secretions except sweat, non intact skin, and mucous membranes -respiratory hygiene/cough etiquette -safe injection practices
nursing interventions to prevent falls
-Complete a risk assessment. -Indicate risk for falling on patient's door and chart. -Keep bed in low position. -Keep wheels on bed and wheelchair locked. -Leave call bell within patient's reach. -Instruct patient regarding use of call bell. -Answer call bells promptly. -Leave a night light on. -Eliminate all physical hazards in the room (clutter, wet areas on the floor). -Provide nonskid footwear. Leave water, tissues, bedpan/urinal within patient's reach. -Document and report any changes in patient's cognitive status to the physician and other nurses at the change of shift. -Use alternative strategies when necessary instead of restraints. -As a last resort, use the least restrictive restraint according to agency policy. If restraint is applied, assess patient at the required intervals.
FLACC scale
-Faces -Legs -Activity -Cry -Consolability -for infants 2 months to 7 years who are unable to validate the presence of or quantity the severity of the pain
Beyer Oucher pain scale
-For use in young patients, combines a 0-to-100 scale with six photographic images of children in pain. This scale is helpful for use with older children. Adaptations of the Oucher pain scale are also available for various ethnic groups.
questions to ask while examining skin
-How long have you had this problem? -does it bother you? -how does it bother you? -have you found anything helpful in relieving these symptoms?
types of medication errors
-Inappropriate prescribing of the drug -Extra, omitted, or wrong doses -Administration of drug to wrong patient -Administration of drug by wrong route or rate -Failure to give medication within prescribed time -Incorrect preparation of a drug -Improper technique when administering drug -Giving a drug that has deteriorated
Chronic/Persistent Pain (Non-Cancer Pain)
-Is not protective and serves no purpose, lasts longer than 6 months and is constant or recurring with a mild-to-severe intensity. -Does not always have an identifiable cause, and leads to great personal suffering. -Chronic pain is a major cause of psychological and physical disability, leading to problems such as job loss, inability to perform simple daily activities, sexual dysfunction, and social isolation.
Acute/Transient Pain
-Is protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response. -It eventually resolves, with or without treatment, after an injured area heals. -Because acute pain has a predictable ending (healing) and an identifiable cause, health team members are usually willing to treat it aggressively. -Unrelieved acute pain can progress to chronic pain.
Topical drug preparations
-Liniment -lotion -ointment -suppository -transdermal patch
origin of pain
-Physical: cause of pain can be identified -Psychogenic: cause of pain cannot be identified -Referred: pain is perceived in an area distant from its point of origin (usually with internal organs)
Body's defense against infection
-Skin and mucous membranes (first line defense) -Body's normal flora (first line defense) -Inflammatory response (helps neutralize and control or eliminate the offending agent) -Immune response
The Joint commission role in patient safety
-The product of individual & group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization's commitment to quality & patient safety -Identify patients correctly -use medicines safely -use alarms safely -prevent infection -identify patient safety risks -prevent mistakes in surgery
ear and nose care
-Wash external ear with washcloth-covered finger; do not use cotton-tipped swabs. -Perform hearing aid teaching and care if indicated. -Clean nose by having patient blow it if both nares are patent. -Remove crusted secretions around nose by applying warm, moist compress.
Assessment
-What you think the problem is (cardiac, infection, neurological, respiratory) -You may not be sure of the problem -does the patient seem unstable and may get worse?
Situation
-Who the patient is -The patients code status -The problem or reason for conversation -Vital signs and assessment -What your concerns are and why
mobility and safety
-a limitation in mobility is unsafe -an older adult with an unsteady gait is more prone to falling -people with partial paralysis -people who use supportive devices like canes, walkers and wheelchairs -people who recently have had surgery or a prolonged illness that affect the patients mobility -nurses must assess a patients risk for injury with a view toward maintaining independence and fostering self-esteem while providing a safe and predictable environment
reflective question or comment
-a technique that involves repeating what the person has said or describing the persons feelings -encourages patient to elaborate on their thoughts and feelings Ex. Patient: I've been really upset about my blood pressure and have to take these pills. Nurse: You've been upset... Patient: I guess I'm worried about what could happen if my blood pressure gets too bad.
ability to communicate and safety
-ability to communicate is basic to many safety practices -nurses must assess any factors that may influence the patients ability to receive and send messages -fatigue, stress, medications, aphasia, and language barriers are examples of factors that can affect communication
Blood flow
-absorption is increased with blood flow -patients with impaired circulatory function absorb drugs less rapidly than do patients with normal circulatory function
pH
-acidic drugs are well absorbed in the stomach -drugs that are basic remain ionized or insoluble in an acid environment
reasons for providing back massage
-acts as a general body conditioner -relieves muscle tension and promotes relaxation -provides opportunity for nurse to observe skin for signs of breakdowns -improves circulation -may decrease pain, distress, and anxiety -may improve sleep quality -provides a means of communication through use of touch
intradermal injection
-administered into the dermis, just below the epidermis -has the longest absorption time -sites: inner surface of forearm, upper back, and under scapula -A 1/4″ to 1/2″, 25- or 27-gauge needle is used and the angle of administration is 5 to 15 degrees. -dosage is usually small <0.5mL
allergic effects
-adverse effect -anaphylactic reaction -immune response that occurs when the body interprets an administered drug as a foreign substance and forms antibodies against the drug
idiosyncratic effect
-adverse effect -any usual response to a drug that may manifest itself by over response, under-response, or even the opposite of the expected response
drug tolerance
-adverse effect -occurs when the body becomes accustomed to the effects of a particular drug over a period of time -larger doses of the drug must be taken to produce desired effect
toxic effect
-adverse effects -groups of symptoms related to drug therapy that carry risk for permanent damage or death
OSHA guidelines on lifting
-advocates of "no-lift policy" -recommends use of mechanical lifting devices for moving patients -do not lift anything heavier than 35 lbs with out assist device -ensure enough staff is around and available to help -assess area for clutter and accessibility -decide which equipment to use -plan carefully what you will do before moving the patient
handeling controlled substances
-all medication systems should be locked -sometimes controlled substances are in a double locked system -a record must be kept for each narcotic that is administered *Required information*: -name of patient -amount of substance used -hour the controlled substance was given -name of the prescribing provider -name of the nurse who administered the substance
open-ended questions or comment
-allows patients to express what they understand to be true, yet is specific enough to prevent digressing from the issue at hand -it encourages free verbalization -it prevents the patient from giving a simple yes or no that can be limiting Ex. -What did your healthcare provider tell you about your need for this hospitalization?
physical health state and safety
-anything that affects the patients health state can potentially affect the safety of the environment -healthcare of chronically ill or weakened patients includes preventing accidents as well as promoting wellness and restoration of healthy state
nail and foot care
-asses nails for color and shape, intactness and cleanness and ternderness -check history of foot and nail problems -soak nails and feet and assist with cleaning and trimming -massage feet to promote relaxation and comfort -provide diabetic foot care if indicated
nursing process for fall prevention
-assess for history of falls or accidents -note assistive devices -be alert to history of drug or alcohol abuse -obtain knowledge of family support systems and home environment -assess specific risk factors, the environment, and the person (pt, caregiver, healthcare team, family)
perineal and vaginal care
-assess for problems -perform physical assessment of male and female genitalia -perfomr perineal care in a matter-of-fact and dignified manner according to procedure -cleanse vaginal area with plain soap and water
safe patient transfer
-assess the patient, know their medical diagnosis, capabilities, and any movements not allowed -assess patients ability to assist with movement and encourage patients to assist in their own transfers -assess patients ability to understand instructions and cooperate with staff
knowledge and safety
-awareness of safety and security precautions is crucial for promoting and maintaining wellness throughout the lifespan -patients need instructions to adhere to a medical regimin or to follow safety precautions when oxygen is in use -patients require certain amount of knowledge to manage new equipment and unfamiliar procedures -they need to be able to identify potentially threatening circumstances -*patient teaching is crucial*
ensuring bedside safety
-bed is in lowest position -bed position is safe for patient -bed controls are functioning -call light is functioning and always within reach -side rails are raised if indicated -the wheels or casters are locked
failure to perceive the patient as a human being
-blocks communication -nurses must focus on the whole patient and not merely diagnosis -patients should be addressed by a formal name (Mr. Mrs.) rather than slang (honey, sweetie)
changing the subject
-blocks communication -patient might be at a point of readiness to discuss something and will likely feel frustrated if put off by a change in subject Ex. Patient: When can I expect to be told about my insulin? Nurse: Let's discuss your diet now so that you will know what to eat when you get home. We can discuss your insulin some other time
failure to listen
-blocks communication -patients may not feel that they are able to speak freely to their nurse -dont miss valuable opportunities for important communication by approaching patients with a closed mind or focusing on your own needs rather than the patients -you must have confidence in your ability to meet the challenges of the patient
using side rails as restraints
-can pose serious risks for a confused or agitated patient -a person of small stature can asphyxiate by becoming wedged between mattress and bedframe -most injuries from siderail entrapment are frail, of advanced age, or confused
Gossip and rumor
-can produce detrimental effects on relationships and group building -could damage the reputation of others -can cause blocks in team building
medication cart
-cart with meds for multiple patients all in different drawers -a computer is usually on top of the cart to access the patients medical records
lipid solubility
-cell membranes have a fatty acid layer -a drug that is more lipid soluble can be absorbed more readily and pass more easily through the cell membrane
lifestyle and safety
-certain occupations and recreational activities place people in more hazardous situations ex: -healthcare staff who suffer sleep deprivation due to extended work hours and variable shifts assignments are more likely to commit errors and be a factor in adverse events
medication errors
-check patients condition immediately -notify nurse manager and primary care provider -write description or error and remedial steps taken on medical record -complete form used for reporting errors, as dictated by facility policy (special event, event, unusual occurrence report)
assessments made prior to moving patient
-check the medical record for any conditions or order limiting mobility -perform a pain assessment prior to the time for the activity -if the patient reports pain, administer medication -assess the patients ability to assist with moving and the need for assistants or equipment -assess the patients skin for signs of irritation, redness, edema, or blanching
developmental level and hygiene
-children learn hygiene while growing up and they learn from family practices -adolescents may bathe more frequently due to concerns of appearance and acne -as age increases, time spent bathing decreases which can lead to skin conditions or problems
clarifying question or comment
-clarifying question or comment to gain an understanding of a patients comment -can prevent possible misconceptions that could lead to an inappropriate nursing diagnosis -overuse can lead to a patient believing that the nurse is not listening or lacks appropriate knowledge Ex. Patient: I have never needed to take medicine before in my life. Nurse: Is this the first health problem you have had?
care of eyes
-clean from inner to outer canthus with wet, warm cloth, cotton ball or compress -use artificial tear solution or normal saline every 4 hours if blink reflex is absent -care for eyeglasses, contact lens or artificial eye if indicated
factors to consider while examining skin
-cleanliness -color -temperature -turgor -moisture -sensation -vascularity -evidence of lesions
culture and person hygiene
-cleanliness and hygiene can differ between cultures -in some cultures it is considered unclean to not shower daily and use deodorants -some people find weekly baths sufficient and don't use deodorants -bathing can also be a private or communal activity
purpose of bathing
-cleanses skin -acts as conditioner -relaxation -promotes circulation -serves as musculoskeletal exercise -stimulates rate and depth of respirations -promotes comfort -provides person with sensory input -helps improve self-image -strengthens nurse-patient relationship
nontherapeutic comments and questions
-cliches -questions requiring only a yes or no answer -questions containing the word why or how -questions that probe for information -leading questions -comments that give advice -judgmental comments
bar-code medication administration
-computerized bar coded administration system -each patient and each nurse is identified by a bar code -each drug is also packaged with a bar code to identify the form and dosage -confirms patient and meds and reduces room for error -alerts nurse to discrepancies
factors that affect the pain experience
-culture -ethnic variables -family -sex -gender -age -support -environment -anxiety and fear -previous pain experiences
factors affecting personal hygiene
-culture -socioeconomic class -spiritual practices -developmental level -state of health -personal preferences
effects of immobility
-decreased muscle tone, size and strength -decreased joint mobility and flexibility -limited endurance and activity tolerance -bone demineralization -lack of coordination and altered gait -decreased ventilatory effort and increased respiratory secretions, atelectasis, and respiratory congestion -increased cardiac workload -orthostatic hypotension -venous thrombosis -impaired circulation and skin breakdown -urinary stasis -infection -altered sleep patterns, pain, depression, anger and anxiety
factors that affect safety
-developmental considerations (age,risk of cross infection, taking universal precautions) -lifestyle -social behavior -environment -mobility -sensory perception -knowledge -ability to communicate (SBAR) -physical and psychosocial health state
health state and hygiene
-disease, surgery, or injury may reduce a persons ability to perform hygiene measures or motivation to follow usually hygiene habits -weakness, dizziness and fear of falling may prevents a person from bathing or showering, especially lower extremities
disruptive interpersonal behavior and communication
-disruptive behavior has a negative effect on clinical outcomes and interpersonal relationships -adverse effects occurs when communication between health care professionals is ineffective, abusive, or negative -must follow a code of conduct defining acceptable, disruptive, and unacceptable behavior
Nonpharmacologic Pain Management
-distraction -humor -music -imagery -relaxation -cutaneous stimulation -acupuncture -hypnosis -biofeedback -therapeutic touch -animal-facilitated therapy
gait belts
-do not use on patients with abdominal or thoracic incisions -used for transferring patients and assisting with ambulation, providing a firm grasp for the caregiver and facilitating transfer -belt is placed on patients waist and secured by velcro fasteners
developmental considerations and safety
-each developmental level carries its own risks -healthcare needs and safety risks change as people progress from infancy to the older adult stage -physical and cognitive changes reflect the sequential development stages
Lab data indicating infection
-elevated WBC count (normal range 5,000-10,000/mm^3) -increased specific types of WBCs -elevated erythrocyte sedimentation rate -presence of pathogen in urine, blood, sputum, or draining cultures
Nursing interventions for pain
-establishing trusting nurse-patient relationship -manipulating factors affecting pain experience -initiating nonpharmacologic interventions -reviewing additional pain control measures -considering ethical and legal responsibility to relieve pain -teaching patient about pain
Passive Range of Motion (ROM)
-exercise performed by nurse with no patient participation
active range of motion
-exercises done independently by patient -no participation by nurse or others
socioeconomic class and culture and hygiene
-financial resources can affect how clean a person is -people may not even have access to a bath or shower or can afford soap and shampoo
physical assessment for mobility
-general ease of movement and gait -alignment -joint structure and function -muscle mass, tone, and strength -endurance
Maintaining a safe environment
-good lighting -work alone when prepping meds -dont leave meds unattended -lock meds - lock cart - prepper must also be the administrator -dont administer meds if you are distracted or interrupted
providing hair care
-identify patients usual hair and scalp care practices and styling preferences -note any history of hair or scalp problems (dandruff, hair loss, baldness) -treat any infestations -groom and shampoo hair -care for beards and mustaches -assist with unwanted hair removal
safety considerations for older adults
-identify safety hazards in the environment -modify the environment as necessary -attend defensive driving courses or courses designed for older drivers -encourage regular vision and hearing tests -ensure hearing aids and eyeglasses are available and functioning -have operational smoke detectors in place -objective document and report any signs of neglect and abuse Why? -accidental injuries occur more frequently in older adults because of decreased sensory abilities, slower reflexes, and reaction times -collaboration between family and healthcare providers can ensure a safe, comfortable environment and promote healthy aging
use of walkers
-improve balance by increasing patients base of support -walkers with wheels are best for patients with a gait that is too fast or who have difficult lifting the walker -these patients do not rely on the walker to bear weight -can be difficult to maneuver -the top of the walker should line up with the crease on the inside of the patients wrist when arms are relaxed at patients sides -when hands are place on the grips the elbows should be flexed about 30 degrees -the walkers rubber tips should be intact to prevent slipping
Exercise and Urinary system
-increases blood circulation which improves blood flow to kidney -allows kidneys to maintain body fluid balance and acid-base balance more efficiently
factors affecting host susceptibility
-intact skin and mucous membranes -normal pH levels -WBC count -Age, sex, race, hereditary factors -immunizations (natural or acquired) -fatigue -climate -nutritional and general health status -stress -use of invasive or indwelling medical devices
factors that contribute to falls
-lower body weakness -poor vision -gait and/or balance issues -problems with feet and/or shoes -use of psychoactive medications -postural dizziness -hazards in the home -advanced age -fear of falling -chronic conditions (arthritis, diabetes, stroke, Parkinsons, incontinence, dementia)
Chronic pain
-may be limited, intermittent, or persistent -lasts beyond the normal healing period -periods of remission or exacerbation are common
Giving false assurance
-might give patients the impression that things are going to turn out well even when knowing the chances are not good -they may also give the impression that the nurse is not interested in their problems -use of cliches gives a patient false assurances
administering oral hygiene
-moistening the mouth -cleaning the mouth -caring for dentures -toothbrushing and flossing (place brush at 45 degree angle to gum line) -using mouthwashes
incident reporting
-must be completed after any accident or incident in a health care facility that compromises safety -describes the circumstances of the accident or incident -details the patient's response to the examination and treatment of patient after the incident -completed by the nurse immediately after the incident -it is not a part of the medical record and should not be mentioned in documentation
positioning patients in bed
-must maintain correct body alignment that facilitates physiologic functioning *You can use*: -foam wedges and pillows -matresses that are firm but have give -adjustable beds -trapeze bar -cradles -trochanter rolls -hand and wrist splints -side rails -foot boards, boots
hours of sleep care
-offer assistance with toileting, washing, and oral care -offer back massage -change any soiled bed linens or clothing -position patient comfortably -ensure that call light and other objects patient requires are within reach
as needed (PRN) care
-offer individual hygiene measures as needed -change clothing and bed linens of diaphoretic patients -provide oral care every 2 hours if indicated
Wong-Baker FACES
-pain rating scale asks children to compare their pain to a series of faces ranging from a broad smile to a tearful grimace -Adults and children >3 in all patient care settings
stand-assist and repositioning aids
-patient must be partially dependent, cooperative, with good upper body mobility and strength with bearing capabilities -help patient to stand
basic methods of assessing pain
-patient self-report -identify pathologic conditions or procedures that may be causing pain; consider physiologic measures -report of family member or other close person -nonverbal behaviors(restlessness, grimacing, crying, clenching fists, protecting painful area) -physiologic measures (increased BP and HR) -attempt an analgesic trial and monitor results
self care patients
-patients who are capable of managing their personal hygiene independently once oriented to the bathroom -still offer back massage and spend time assessing the patients day to day needs
social behavior and safety
-people who are inclined to take risks and jeopardize their safety (failure to wear seatbelts or follow safety precautions) -stress can precipitate an unhealthy lifestyle -use of drugs -vulnerable populations
prodromal stage
-person is most infectious -vague and non-specific signs of disease
risk of restraints
-physical restraints can increase the possibility of serious injury due to a fall (they do not prevent falls) -use of restraints can cause skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration, respiratory difficulties, and even death
medical asepsis
-practices designed to reduce the number and transfer of pathogens; synonym for clean technique
full stage of illness
-presence of specific signs and symptoms of disease
zero harm in healthcare initiative
-preventing falls, pressure ulcers, hospital acquired infections -process improvement -developing and adopting a culture of safety -accountability for safety and quality -getting rid of complications from care -preventing harm for employees -*accreditation in compliant hospitals/facilities*
bed bath
-provide materials needed -provide privacy -remove top linens and replace with bath blanket -place cosmetics in convenient place -assist patients who cannot bathe themselves completely
closed question or comment
-provides the receiver with limited choices of possible responses and might ofter be answered by one or two words, "yes" or "no" -used to gather specific information from a patient and to allow the nurse and patient to focus on a particular area -can often be a barrier to effective communication Ex. -What medicines have you been taking at home?
interviewing techniques
-purpose is to obtain accurate and thorough information -interviewing is a major tool for collecting data during assessment -all interviews should begin with an explanation of the purpose of the interview
Partial care patients
-receive morning hygiene care at the bedside or seated near a sink in the bathroom. -they usually require assistance with body areas that are difficult to reach
single ended canes with half circle handle
-recommended for patients requiring minimal support and those who will be using stairs frequently
single ended canes with straight handle
-recommended for patients with hand weakness because the hand grip is easier to hold -not recommended for patients with poor balance
signs of acute infection
-redness -heat -swelling -pain -loss of function
Lateral-assist devices
-reduces patient-surface friction during side-to-side transfers -roller boards -transfer boards -inflatable mattresses(hover mat) -risk for caregiver injury related to horizontal reach and posture required
Spiritual practices and hygiene
-religious beliefs may affect hygienic practices -in orthodox jews, ritual baths are required for women after childbirth and menstruation -some culture prohibit modern facilities which hinder their bathing
safety considerations for adults
-remind them of effects of stress on lifestyle and health -enroll in defensive driving course -evaluate workplace for safety -counsel about domestic violence Why? -visible signs of aging may become apparent -lifestyle behaviors and situational or family crises can impact an adults overall health and cause stress -preventative health practices help adults improve the quality and duration of life
Complete care patients
-require assistance with all aspects of personal hygiene -a complete bed bath is done or patient is taken to shower
environment and safety
-risk for exposure to potentially unhealthy substances in the environment -living in high-crime neighborhoods -facilities must have up-to-date worksite analyses to recognize patterns of violence -lack of star handrails -poor stair design -lack of bathroom grab bars -dim lighting or glare -obstacles/tripping hazards -slippery or uneven surfaces -psychoactive medications -improper use of assistive devices
factors affecting absorption of medications
-route of administration -lipid solubility -pH -blood flow -local conditions at the site of administration -drug dosage
criteria for choosing equipment for injections
-route of administration -viscosity of the solution -quantity to be administered -body size -type of medication
Unit dose supply
-self-contained packet that holds one tablet or capsule -each patient is supplied with the medication needed for a period of time
validating question or comment
-serves to validate what the nurse believes he or she has heard or observed -overuse may lead to patient thinking that he or she is not listening Ex. - At home, you have been taking both a water pill and a blood pressure pill every day. Did you take them today?
mechanical lateral-assist devices
-slide patient from stretcher to bed with out lifting
personal preferences of hygiene
-some people prefer showers over baths and vice versa -some use bathing as a form of relaxation -people ideas of cleanliness differ -women can use hygienic products following intercourse to promote cleanliness
Directing question or comment
-sometimes it is necessary to obtain more information about a topic brought up earlier in the interview or to introduce a new aspect of the current topic -nurse can gain additional valuable information that aids in assessing patients health status and educational or counseling needs.
subjective data
-the "A" and "R" -information from your point of view that you have gathered from the patients condition and status
drug dosage
-the amount of a drug administered directly impacts its bioavailability -ex, loading dose
local conditions at the site of administration
-the more extensive the absorbing surface, the greater the absorption and the more rapid the effect -ex, pt with burns will would have poor absorption from an IM injection because of damage of blood supply -fatty food slows the rate of gastric emptying, which can slow rate of absorption -other foods may enhance rate of absorption
afternoon (PM) care
-toileting -handwashing -oral care -straighten bed linens -help patient with mobility to reposition
variable leading to back injury in health care workers
-uncoordinated lifts -manual lifting and transferring of patients with out assistive devices -lifting when fatigued or after recent back injury recovery -repetitive movements such as lifting, transferring, and repositioning patients -standing for long periods of time -lifting and transferring patients -repetitive tasks -transferring/repositioning uncooperative or confused patients
Droplet precautions
-used for infections that are spread by large-particle droplets (rubella, mumps, diphtheria, adenovirus, flu) -use a private room -wear PPE -transport patient only when necessary, have them wear surgical mask if possible -visitors remain 3ft from infected person
Airborne precautions
-used for infections that spread through air (ex. tuberculosis, varicella) -must be in a negative pressure room -must wear respirator -transport patient out of room only when necessary and place surgical mask on them if possible -consults CDC guidelines
friction-reducing sheets
-used for moving patients up in bed, turning or repositioning -reduces friction and force on patients skin
powered stand-assist and repositioning lift
-used for patients who are cooperative with ability to bear weight -assists patient to stand with no lifting -sling is placed around the patients back and under the arms -the device mechanically assists the patient to stand, with out assistance from nurse
Contact precautions
-used for patients who are infected or colonized by a multi-drug resistant organism (MDRO) -place in private room -wear PPE -limit movement of pt out of the room -avoid sharing patient-care equipment
Walker use instruction
-wear no-skid shoes or slippers -use chair arms for support when rising from a seated position, then place one hand at a time on walker -begin by pushing the walker forward, keeping the back upright, place one leg inside the walker, keeping the walker in place. Then step forward with remaining leg into the walker, keeping the walker still -caution patient to avoid pushing the walker out too far in front and leaning over it, patients should always step into the walker -never attempt to used a walker on stairs
Recommendation
-what you think the physician should do (Upgrade to ICU, come see the patient, talk to patient or family about code status, ask a consultant to see patient now) -are there any tests needed? (CXR, ABG, EKG, CBC, BMP) -if there's a change in treatment make sure to ask how often they want vital signs, how long they think the problem will last, what should you do if the patients condition doesn't improve?
use of canes
-widen a persons base of support and improve balance -they come in three variations, single ended with half circle handles, single ended with straight handles, and tripod or four pronged -many canes are adjustable -should fit so that when patient stands with the canes tip 4 inches to the side of the foot
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? 1 "We have no record of that client on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 "The client has requested that no information be given out. You'll need to call the client directly." 4 "It is against the hospital's policy to provide you with any information regarding any of our clients."
1 The response "We have no record of that client on our unit. Thank you for calling." conforms to the request that no information be given regarding the client's condition or presence in the hospital. HIPAA laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others. Hospital policies do not prohibit the provision of information to others as long as the client consents. The response "It is against the hospital's policy to provide you with any information regarding any of our clients." also implies that the client is admitted to the facility.
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.
1 A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis. Ph-7.35-7.45 PCO2 - 35-45 HCO3 - 22-30
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1 If the client is allowed to give consent 2 The client cannot make informed decisions about health care. 3 If the client is permitted to give voluntary consent when parents are not available 4 The client probably will be unable to choose between alternatives when asked to consent
1 A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? 1 Isotonic 2 Isomeric 3 Hypotonic 4 Hypertonic
1 Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure, because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications
1 Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.
A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1 Alcohol 2 Caffeine 3 Saw palmetto 4 St. John's wort
1 Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.
Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? 1 Give the infant to the client and instruct her regarding the infant's care. 2 Explain to the client that she can leave, but her infant must remain in the hospital. 3 Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. 4 Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge
1 When a client signs herself and her infant out of the hospital, she is legally responsible for her infant. The infant is the responsibility of the mother and can leave with the mother when she signs them out.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1 White blood cell (WBC) count of 15,000 mm3 2 Negative protein in the urine 3 Blood urea nitrogen (BUN) of 20 mg/dL 4 Prothrombin of 12.0 seconds
1 White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.
steps of the nursing assessment
1) collection and verification of data from a primary source, and secondary sources 2) the analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care
Goals of nursing practice
1) to promote health 2) to prevent illness 3) to restore health 4) to facilitate coping with disability or death Nurses accomplish these goals by using knowledge, skills, and critical thinking
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose.
1,2,4 Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs
1,2,5 With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation
1,3 Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members.
A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. 1 Ask the client what is the client's acceptable level of pain. 2 Eliminate all activities that precipitate the pain. 3 Administer the pain medications regularly around the clock. 4 Use a different pain scale each time to promote patient education. 5 Assess the client's pain every 15 minutes
1,3 The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals.
The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear
1,3,4 Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops.
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning of procedure. 4 Instill the solution directly onto cornea. 5 Press on the nasolacrimal duct after instilling the solution.
1,3,5 Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.
The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. Correct 1 Performing a bed bath for a client on bed rest 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered Correct 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy
1,4 Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.
An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes
1,4,5 When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.
How far should you insert a thermometer when getting a rectal temperature?
1-1.5 inches
How long should you wait between lying, sitting, and standing, when taking orthostatic vital signs?
1-3 minutes
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot
D) Move the chair parallel to the right side of the bed, and stand the client on the right foot (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.
D) Notify the healthcare provider of the family's request The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions
D) Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.
D) Re-oxygenate the client before attempting to suction again Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.
A client with a seizure disorder is taking phenytoin (Dilantin ). A sample for a serum phenytoin level is drawn and the nurse determines that the medication therapy is within therapeutic range if the laboratory result is:
1. 3 mcg 2. 8 mcg 3. 16 mcg 4 24 mcg
Adult client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). The nurse reviews the clients records and reports which of the following serum potassium levels before administering the dose of furosemide ?
1. 3.2 mEq/L 2. 3.8 mEq/L 3. 4.2 mEq/L 4. 4.8 mEq/L
Adult client with a critical high potassium level has received sodium polystyrene sulfate (Kayexalate). The nurse determines that the medication has brought the potassium level back into normal range when the serum potassium level is:
1. 3.3 mEq/L 2. 4.9mEq/L 3. 5.8mEq/L 4. 6.2 mEq/L
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A) Explain that anyone who speaks her language can answer her questions. B) Provide a translator only in an emergency situation. C) Ask a family member or friend of the client to translate. D) Request and document the name of the certified translator.
D) Request and document the name of the certified translator A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred.
A nurses assisting with caring for a client who has received a transfusion at platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which is the following ?
1. And increase hematocrit level 2. And increasing hemoglobin level 3. I declined the temperature to normal 4. A decrease in oozing from puncture sites and gums
A nurse is recording in end-of-shift report for a client. What information needs to be included?
1. As needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since he admission 4. Total number scheduled medications that the client received on that shit
What is the principle-based approach to bioethics?
1. Autonomy 2. Nonmaleficence 3. Beneficence 4. Justice 5. Fidelity 6. Veracity, accountability, privacy, and confidentiality
A Hispanic American mother brings her child to the clinic for an examination. which of the following is most important when gathering data about the child?
1. Avoiding eye contact 2. Using body language only 3. Avoid speaking to the child 4. Touching the child during the examination
A client is receiving a blood transfusion rings The call bell for the nurse. When entering the room, The nurse notes that the client is flushed, dyspneic, complaining of generalized itching. The nurse interprets that The client is experiencing:
1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. A transfusion reaction
A low-sodium diet has been prescribed for a client with hypertension. Which of the following foods, if selected from the menu by the client would indicate an understanding of this diet?
1. Baked turkey 2. Tomato soup 3. Boiled shrimp 4. Chicken gumbo
A nurse has been instructed to discontinue an IV line. Nurse removed the catheter by withdrawing catheter While applying pressure to the site with a:
1. Band-Aid 2, alcohol swab 3. Betadine swab 4. Sterile 2x2 gauze
A Nurse arrives at work and is told to report to the pediatric unit for the day because unit is understaffed and needs additional verses to care for the children. The nurse has never worked in the pediatric unit. which of the following is an appropriate nursing action?
1. Call the hospital lawyer 2. Call the nursing supervisor 3. Refused to flip to the pediatric unit 4. Report to the pediatric unit and Identify tasks that can be safely perform
Unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the clients life. With regard to informed consent for the surgical procedure which of the following is the best action?
1. Call the nursing supervisor to initiate a court order for the surgical procedure 2. Try calling the clients spouse to obtain telephone consent before the surgical procedure 3. Ask the friend who accompanied the client to the emergency department to sign the consent form 4. Transfer the client the operating department immediately, as required by healthcare provider, without obtaining an informed consent
What are the roles of a nurse?
1. Caregiver 2. Communicator 3. Educator 4. Counselor 5. Leader 6: Researcher 7. Advocate 8. Collaborator
What are the six essential features of professional nursing? (Generally speaking).
1. Caring relationships that facilitate health and healing. 2. Being aware of the range of human responses to health and illness in their various environments. 3. Integrating objective date with the patient's or groups subjective experience. 4.Applying scientific knowledge to care for the patient, through the use of critical thinking. 5. Learning through scholarly inquiry. 6. Influence on the promotion of social justice.
The nurse on the dayshift is assigned to care for the following six clients. This in order of priority how the nurse would plan to check his sign clients.
1. Client who requires medication at 10 AM 2. Client who has a tracheostomy and is on mechanical ventilator 3. Client who has diagnosed with diabetes mellitus and he was scheduled for discharge to go home 4. Client who requires before breakfast insulin 5. Client who scheduled for physical therapy in the afternoon 6. Client who scheduled for cardiac catheter at 9 AM
A nurse enters a clients room and notes that the clients lawyer is present and that the client is preparing a living will. The living will requires that the client signature being witnessed, and the client asked the nurse to witness the signature. Which of the following is an appropriate nursing action?
1. Declined to sign the will 2. Sign the will as a witness to the signature 3. Called the hospital lawyer before signing the will 4. Sign the will, clearly identifying credentials and employment agency
The nurse reviews and clients electrolyte results and notes a potassium level of 5.5. The nurse understands that a potassium dial at this level would be noted with which condition?
1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives
A nurse has delegated several nursing tasks to staff member. The nurses primary responsibility after the delegation of the task is to:
1. Document that task was completed 2. Assigned the task that were not completed to the next nursing shift 3. Allow each staff member to make judgments when performing the task 4. Perform follow up with each staff member regarding A performance of the task and the outcomes related to the implementation of the tasks
A nurses caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed in the serum calcium level is 12. On the basis of this laboratory value the nurse takes which action?
1. Documents to value on the clients record 2. Informs the nurse of the laboratory values 3. Places the laboratory result form in the clients record 4. Reassures the client the laboratory results is normal
Client is going to be transfused with a unit of packed red blood cells. The nurse understands that it is necessary to remain with the client for what time. After the transfusion started?
1. Five minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes
A nurses caring for client with a healthcare Association infection. Caused by methicillin-resistant staphylococcus Aureus Who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items would be required to perform this procedure?
1. Gloves and gown 2. Gloves goggles 3. Gloves gown and goggles 4. GLoves gown and shoe protectors
An adult female client has a h hemoglobin level of 10.8g. The nurse interprets that this result is most likely the result of which of the following factors in the clients history?
1. Heart failure 2. Dehydration 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease
A nurses told that the laboratory results for the serum digoxin level is 2.4. The nurse plans to do which of the following?
1. Hold the medication 2. Check the clients last respiratory rate 3. Record the normal you value on the clients flowsheet 4. Administer the next ascend the medication schedule
Hey licensed practical nurse is planning The client the assignment for the day. Which of the following is most appropriate assignment for the nursing assistant?
1. I client who requires wound irrigation 2. Hey client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent file signs after a cardiac catheterization
An older woman is brought to the emergency department. When caring for the client, The nurse notes old and new ecchymotic areas on both of the clients arms and buttocks. The nurse asked the client how the bruises were sustained. The client although reluctant tell the nurse and confidence that her daughter frequently hits her if she gets in the way. Which of the following is the appropriate nursing response?
1. I have legal obligation to report this type of abuse 2. I promise I won't tell anyone but let's see what to do about this 3. Let's talk about the ways that will prevent your daughter from hitting you 4. This should not be happening. if it happens again you must call the emergency department.
A. Mother calls a neighborhood nurse and tells the nurse that her three-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to immediately:
1. Induce vomiting 2. Call the ambulance 3. Call poison control center 4. Bring the child to the emergency department
A nurses caring for client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs with the nurse expect to note in this client if hyponatremia is present?
1. Intense thirst 2. Slow bounding Pulse 3. Dry mucous membranes 4. Postural blood pressure change
A client having problems with blood clotting. which food items with the nurse encouraged client to eat?
1. Legumes 2. Citrus fruits 3. Vegetable oils 4. Green leafy vegetables
A nursing student is asked to identify the practices and beliefs of the Amish society select all that apply.
1. Many choose not to have health insurance 2. They believe that health is a gift from God 3. Hey authority of women is equal to that of men 4. They remains included and avoid helping others 5. They use both traditional and alternative health care such as healers, herbs and massage 6. Panels are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple without adornment.
The nurses told that the blood gas results indicate a pH of 7.50 and a PCO2 of 32 mmHg. The nurse determines that these results indicate:
1. Metabolic acidosis 2. Metabolic Alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
A nurses caring for a client with nasogastric tube that is attached to those section. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
A nurses caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that the client is at risk for developing which acid-base disorder?
1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
Nurses game for a client with a diagnosis of chronic obstructive pulmonary disease. Nurse monitors the client for which acid-base imbalance that most likely occurs in clients with this condition?
1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
A nurse instructed client to increase the amount of riboflavin in the diet. The nurse tells the client to select which food item that is high in riboflavin ?
1. Milk 2. Tomato 3. Citrus fruits 4. Green leafy vegetables
What are the 6 QSEN competencies?
1. Patient-centered care 2. Teamwork and collaboration 3. Quality improvement 4. Safety 5. Evidence-based practice 6. Informatics
A client has a following laboratory values: PH 7.55, HCO level of 22mmHg, and a PCO of 30 mmHg. What should the nurse do?
1. Perform Allen's test 2. Prepare the client for dialysis 3. Administer insulin as prescribed 4. Encourage the client to slow down breathing
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification. Correct Answer: B
Client who was receiving a blood transfusion has experience a transfusion reaction.the nurse sends the blood bag that was used for the client to which of the following areas?
1. Pharmacy 2. Laboratory 3. Blood bank 4. Risk management department
A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, hail, and swollen and that the IV has stop running. The nurse determines that which of the following was probably occurred ?
1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis
The nurses checking the insertion site of a peripheral IV catheter. The nurse to site to be redden, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interpretative that this is likely the result of:
1. Phlebitis of the van 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material
A licensed practical nurse enters A clients room and find the client sitting on the floor. The LPN called the register Nurse who checks the client thoroughly and then assisted client back into bed. The LPN completes the next incident report and the nursing supervisor and healthcare provider are notified of the accident. which of the following is the next nursing action regarding the incident?
1. Place the incident report the clients chart 2. Make a copy of the incident report for the HCP 3. Document incomplete entry in the clients record concerning the incident 4. Document the clients record that an incident report has been completed
which includes clients are most likely to develop fluid(circulatory) overload? select all that apply
1. Premature infants 2. 101 year old man 3. A client on Renal dialysis 4. A client with congestive heart failure
An emergency department nurse received a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which of the following would be the initial nursing action?
1. Prepare the triage rooms 2. Activate the emergency disaster plan 3. Obtain additional supplies from the central supply department 4. Obtain additional nursing staff to assist with treating a casualties
Healthy people 2020's primary "guidelines" are:
1. Prevent disease, disability, and premature death. 2. Having high health equity, *eliminating disparities,* and improving the health of ALL groups. 3. Create a society that promotes good health for all. 4. Promotes continued high quality of life across all lifespans.
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.
D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C).
Interventions for a stage 2 pressure ulcer
Maintain a moist healing environment (saline or occlusive dressing). Promote natural healing while preventing the formation of scar tissue
A nurse enters a client's room and find the client lying on the floor. The nurse calls the register nurse checks the client and then calls the nursing supervisor and the healthcare provider to inform them of the occurrence. The nurse completes the incident report understanding that it allows for that analysis of adverse client events through:
1. Providing clients with necessary stabilizing treatments 2. A method if promoting quality care and risk management 3. Determining the effectiveness of interventions in relations to their outcomes 4. The appropriate method of reporting to local state and federal agencies
A nurses caring for a client with Cirrhosis . The nurse notes that the client is dyspneic and crackles are heard on auscultation of the lungs. What additional signs with the nurse expect to note in this client if the fluid volume excess is present?
1. Rapid weight-loss 2. Flat hand and nicknames 3. A weak and thready pulse 4. And increasing blood pressure
A nurse is planning to reinforce nutrition instructions to an African American client. When developing the plan the nurse is aware that a common dietary practices of clients with African-American heritage is to eat:
1. Raw fish 2, Redmeat 3. Fried foods 4. Rice as the basis for all meals
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.
D) Upper arm circumference Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.
An adult client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells. Which of the following action by the nurse is most appropriate after reading this report?
1. Report the abnormally low count 2. Report the abnormally high count 3. Place a client on bleeding precautions 4. Place a normal report in the clients medical record
Nurses caring for a client with diabetic Ketoacidosis and documents that the client sit spearing Kuszmaul respiration. Based on this documentation which of the following did the nurse most observed ? .
1. Respirations that sees for several seconds 2. Respirations regular but Abnormally slow 3. Respirations that are labored increased in depth and rates 4. Respirations that are abnormally deep, regular and increased in rate
A nurses assisting with collecting Data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is at least priority during the data collection?
1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular
A Nurse consults with a dietitian regarding the dietary preferences of an Asian-American client. Which of the following foods for the nurse likely include in the diet plan?
1. Rice 2. Fruits 3. Red meat 4. Fried foods
Hey Nurse reviews a client electrolyte results and notes that the potassium level is 5.4. Which the following with the nurse notes on the cardiac monitor as a result of this laboratory value?
1. ST elevation 2. Peaked P-wave 3. Prominent u wave 4. Narrow peaked T wave
A nurses verifying dietary instruction to a client with gout. The nurse tells the client to avoid which food items?
1. Scallops 2. Chocolate 3. Cornbread 4. Macaroni products
A client has died, and a nurse asks family member about the funeral arrangements. A family member refuses to discuss the issue. The nurse appropriate action is to:
1. Show acceptance of feeling 2. Provide information needed for decision-making 3. Suggest a referral to a mental health professional 4. Remain with the family members without discussing funeral arrangements
A nurse is reading the healthcare providers progress notes to clients records and sees that the HCP has documented "insensible fluid boss of approximate 800 mL daily." The nurse understands that this type of food bath can occur through:
1. Skin 2. Urinary output 3. Wound drainage 4. Gastrointestinal tract
A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route?
1. Skin 2. inhalation 3. Gastrointestinal
Hey nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50, A PCO2 of 30, and the nurse is told that the client is experiencing respiratory alkalosis. Which of the following additional laboratory values with the nurse expecting note?
1. Sodium level of 145 2. Potassium level of 3.2 3. Magnesium level at 2.4 4. Phosphorus level of 4.0
A nurses assisting the caring for a client who is receiving a unit packed red blood cells. The nurse tells the client that is most important to report which of the following signs immediately?
1. Sore throat or ear ache 2. Chills itching or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site
And antihypertensive medication has been prescribed for a client with hyper tension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. The nurse should:
1. Tell the client that herbal substance are not safe it should never be used. 2. Advisor client to discuss the use of herbal substances with the healthcare provider 3. Teach the client how to take her blood pressure so that it can be monitored closely 4. Tell the client that if she takes the earth. States she will need to have her blood pressures checked frequently
A nurse employed in a long-term care facility is planning the client assignments for the shift. Which of the following clients with the nurse appropriately assignment nursing assistant?
1. The client requires 24 hour urine collection 2. The client who requires twice daily dressing changes 3 A diabetic client requires Daily insulin and reinforcement of dietary measures 4. The client Who is on a bowel management program and requires rectal suppositories and daily enema
A nurse is assigned to care for four clients. When planning clients rounds which client would the nurse collect data from first?
1. The client scheduled for chest x-ray 2. Client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen visa nasal cannula who have difficulty breathing during previous shift
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time.
D) is disoriented to place and time The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C).
A nurses completed diet teaching for a client who has prescribed a low-sodium diet to treat hypertension. The nurse determines that further teaching is necessary with the client makes which of these statements?
1. This diet will help lower my print pressure
A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse ask the lawyer to describe an example that may relate to invasion of clients privacy. A nursing action that indicates a violation of this right is:
1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs on the client without consent 4. Telling the client that he or she cannot leave the hospital
What are the FOUR aims of nursing?
1. To promote health. 2. To prevent illness. 3. To restore health (alleviate suffering). 4. To facilitate coping with disability or death.
The nurses caring for a client with suspected diagnosis of hypercalemia . Which of the fine signs would be an indication of this diagnosis?
1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness
The client is scheduled for blood to be drawn from the radio artery for an arterial blood gas determination. Nurse assist with performing Allen's test before drawing the blood to determine the adequacy of:
1. Ulnar circulation 2. Carotid circulation 3. Femoral circulation 4. Brachial circulation
Client has a prescription to receive 1000 mL of 5% dextrose and 0.45% sodium chloride. After gathering the appropriate equipment, The nurse takes which action first before spiking the IV bag with the tubing?
1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp of the IV tubing 4. Closes the roller clamp of the IV tubing
A nurse preparing to assist a Jewish client with eating lunch. A kosher mail is delivered to the client. Which nursing action is appropriate with assisting the client with the meal?
1. Unwrapping the eating utensils for the client. 2. Replacing the plastic utensils with metal utensils 3. Carefully transferring the food from paper plates to glass plates 4. Asking the client to unwrap utensils and allowing the client to pay the meal for eating
A nurse is assigned to care for a client with peripheral IV infusion. The nurses providing hygiene care to the client and would avoid which of the following while changing the client hospital gown?
1. Using the hospital gown with snaps on this please 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flowrate immediately after changing the hospital gown 4. Putting the bag and To being through the sleeve, followed by the clients arm
A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encouraged client to eat which dietary items to promote wound healing?
1. Veal, potatoes, gelatin and orange juice 2. chicken breast, Broccoli , strawberries, and milk 3. Peanut butter and jelly sandwich, cantaloupe and Tea 4. Spaghetti with tomato sauce, garlic bread, and ginger out
A nurse is repositioning a quadriplegic client that is laying in supine position. which of the follow is appropriate? A. Support the clients head with a pillow that maintains cervical flexion B. Position the clients shoulders off of the pillow for internal rotation C. place the clients arms at his sides with the elbows extended D. Internally rotate the clients hips by using a trochanter roll
D- CORRECT: Because you want to prevent external rotation of the hips A-INCORRECT: You should use a pillow that does not cause cervical flexion B- INCORRECT: You should use a pillow or blanket to supper the shoulders and prevent internal rotation C- INCORRECT: The elbows should be in flexed position on pillows when the client is supine
A nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. The next action would be to:
1. aim at the base of the fire 2. Squeeze the handle on the extinguisher 3. Sweep the fire from side to side is with the extinguisher 4. Sweep the fire from top to bottom with the extinguisher
The nurses reviewing the health records of assigned client. The nurse plan care knowing that which client is at risk for potassium deficient?
1. the client with Addison's disease 2. Client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction
Cane use instruction
1. the patient stands with weight evenly distributed between feet and cane 2. the cane is held on the patients stronger side and is advanced one small stride ahead 3. supporting weight on the stronger leg and the cane, the patient advances weaker foot forward, parallel with the cane 4. supporting weight on the weaker leg and the cane, the patient brings the stronger leg forward to finish the step
Three checks of drug administration
1. when the nurse reaches for the unit dose package or container 2. after retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multi dose container 3. before giving the unit dose medication to the patient, or when replacing the multi dose container in the drawer or shelf
Hey client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, I have read a lot about complementary therapies do you think that I should try any? The nurseries responds by making which appropriate statement
1. you need to ask your healthcare provider about it. 2. I would try anything that I could if I had cancer. 3. no because it will interact with the chemotherapy 4. There are many different forms of complementary therapy. let's talk about these therapies.
A nurse reviews the client serum calcium level and notes the level is 8. The nurse understands that which condition would cause the serum calcium level?
1.. Prolong bedrest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL
1.5
A nurse employed in the emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?
1.The client complained of muscle aches headache and malaise 2. The client and twisted her ankle when she fell while rollerblading 3. The client with a minor laceration on the Index finger sustained by cutting an eggplant 4. A client with chest pain he states that he just ate pizza that was made with a very spicy sauce
What is the expected pulse rate for an infant?
120-160
What is considered stage 1 hypertension?
140-159/90-99
The healthcare provider prescribes erythromycin (ilosone) 300 mg PO QID. The medication label reads, "ilosone 100mg/5mL" How many mL should the nurse administer at each does? (Enter the numeric value only)
15
The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only)
15
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.
15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B). Correct Answer: B
A pt using a cane should advance the cane _____ to ____ cm at a time to maintain balance.
15-25
How much water should you flush through the NG before and after meds?
15-30 mLs
How much water should you mix meds with when preparing to give through NG tube?
15-30mLs
Normal levels of platelets
150,000 to 400,000/microliter
A client has a prescription for lorazepam (ativan) 1 mg for anxiety. The medication is supplied as 0.5mg tablets. How many tablets should the client take? (enter numeric value only.
2
During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? 1 The nurse also should have instituted a plan to increase activity. 2 The nurse provided supportive nursing care for the well-being of the client. 3 Debridement of the pressure ulcer should have been done before the dressing was applied. 4 Treatment should not have been instituted until the health care provider's prescriptions were received.
2 According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions.
A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? 1 Excessive carbohydrate intake 2 Lack of protein supplementation 3 Insufficient intake of water-soluble vitamins 4 Increased concentration of electrolytes in cells
2 An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.
A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2 The child had a right to remain in the room with the other children. 3 The child had to be removed because the other children needed to be considered. 4 Segregation of the child for more than half an hour was too long a period of time
2 Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated
A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. 1 After reporting severe pain 2 On admission to the hospital 3 Upon entering the operating room 4 Before transfer to a rehabilitation facility 5 At time of scheduling for the surgical procedure
2, 4 Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat
2,4 Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.
The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. 1 Orientation 2 Capillary refill 3 Pupillary response 4 Respiratory rate 5 Pulse and skin temperature 6 Movement and sensation
2,5,6, A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.
How often should you encourage active or do passive ROM?
2-3 times a day
How long can progressive alcohol withdrawal symptoms last?
2-5 days
If a nurse suspects the client has a fecal impaction, what is the most important question to ask? A. What types of food have you been eating? B. Have you been taking stool softeners or laxatives? C. Have you been able to pass gas? D. Have you had small, liquid stools?
D- Have you had small, liquid stools. This is a symptom of a fecal impaction because some stool can seep around the impacted stool.
A nurse is contributing to the plan of care of a client who is on droplet precautions. The nurse should recommend which of the following for the plan of care? A. place client in a negative pressure room B. wear a gown when giving pt medication C. Remove PPE immediately after exiting client's room D. Wear a mask while taking clients vital signs
D- you should wear a mask whenever you are within 3 feet of the pt.
An older client is transferred to the rehabilitation unit with the diagnosis of Cerebrovascular Accident (CVA) with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left leg and states, "There is a leg in my bed!" What is the best response by the nurse? A. "Your stroke has impaired your ability to recognize your paralyzed leg." B. "Look at your legs and you will see that they both belong to you." C. "Please explain to me what you thing happened to your leg." D. "I know you think there is an extra leg in your bed, but I do not see it."
D. "I know you think there is an extra leg in your bed, but I do not see it."
When the nurse asks a male client with Bipolar Disorder if he is going to group session, he responds, "there is no use in me going to that group because all they talk about is Schizophrenia, which doesn't apply to me." Which response is best for the nurse to provide this client? A. "Tell me what medications you are taking right now" B. "You are probably right. The group really does not apply to your condition." C. "It sounds to me like it may be better for you that you stay here" D. "Let's talk about what you may have in common with the other group members."
D. "Let's talk about what you may have in common with the other group members."
Which client should the nurse assess first? A. A young female client who reports that she is afraid of her roommate who is psychotic B. An older client who is asking for a priest to offer Last Rites C. A female client who is anxious about being discharged because she has no assistance at home D. A client who is ambulating with partial weight-bearing after a total hip replacement
D. A client who is ambulating with partial weight-bearing after a total hip replacement
2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limites and her sugar is 325 mg/dL. what intervention should the nurse implement first? A. Give the client 4 ounces of orange juice B. Administer next scheduled dose of metformin (Glucophage) C. Cancel the clients dinner tray D. Administer regular insulin per sliding scale
D. Administer regular insulin per sliding scale
The nurse is planning to ambulate client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first? A. Place non-skid shoes on the client B. Show the client how to use the call light C. Use a gait belt to support the client D. Assist the client to a bedside sitting position
D. Assist the client to a bedside sitting position
The nurse is implementing the plan of care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Describes being very depressed B. Has little appetite and neglects personal hygiene C. Is not interested in the activities of family and friends D. Begins to show signs of improvement
D. Begins to show signs of improvement
The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catherterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take? A. Stand the client to void and run tap water within hearing distance before catheterizing the client. B. Straight catheterize and if the residual uring volume is greater than 100 mL, clamp catheter C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period. D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first? A. Bathe the wound daily with soap and water B. Record the color and temperature of the leg C. Perform dorsal flexion and extension exercises D. Check the client's dorsalis pedis and posterior tibialis pulse point
D. Check the client's dorsalis pedis and posterior tibialis pulse point
The practical nurse is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. What nursing action should the PN take?
Mark the outlined area of drainage with date, time and initials
A male client with Hypercholesterolemia is being discharged with a new prescription for simvastatin (Zocor). The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond? A. Instruct the client that the only regular testing needed is to monitor his cholesterol level B. Teach the client that liver test are usually only done if the client reports symptoms C. Review with the client that renal function tests are needed, rather than liver tests D. Confirm that the client correctly understands the need to monitor liver function regularly
D. Confirm that the client correctly understands the need to monitor liver function regularly
Which technique should the PN use to most accurately assess a clients baseline blood pressure during a routine health examination?
Measure the pressure in each arm while the clients sits with the arm supported at heart level.
The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first? A. Ask the client if she has previously been catheterized B. Position the client and observe the urinary meatus C. Obtain a 30 ml syringe and a vial of sterile water D. Consult with the chage nurse about the catheter
D. Consult with the chage nurse about the catheter
The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throws it across the room and curses loudly. What action should the nurse implement? A. Transfer the medications to another bottle that is easier to open B. Leave the client's home immediately and plan to return later C. Igonore the outburst and demonstrate how to open the bottle D. Describe other types of medication containers that are available
D. Describe other types of medication containers that are available
The nurse is preparing a client for a mammogram. What instructions should the nurse provide the client? A. Do not exercise the upper body on the day of the procedure B. Avoid taking aspirin for one week prior to the procedure C. Avoid eating or drinking 6 hours prior to the procedure D. Do not use underarm deodorant on the day of the procedure
D. Do not use underarm deodorant on the day of the procedure
A client is admitted to the rehabilitation unit after a Thrombotic Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive aphasia. What intervention should the nurse implement to communicate with the client? A. Picture communication board B. Request a family member to interpret C. Electronic larynx device D. Dysphagia precautions
D. Dysphagia precautions
The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional conflict related to concerns about mechanical ventilation." When assigned to care for this client, what intervention should the nurse implement based on this diagnosis ? A. Provide an opportunity for the client to meet with survivors of the disease who have undergone mechanical ventilation B. Remind the client that a mechanical ventilator is usually only needed for a short period of time C. Ask the hospice nurse to visit with the client to discuss his options for care if he chooses not to undergo mechanical ventilation D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation
D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation
A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsis if the amputation is delayed B. Notify the RN that the client's wife needs further explanation about the procedure C. Document on the client record the refusal for surgical treatement D. Encourage the client's wife to express concerns about making the decision
D. Encourage the client's wife to express concerns about making the decision
A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsis if the amputation is delayed B. Notify the RN that the client's wife needs further explanation about the procedure C. Document on the client's record the refusal for surgical treatment D. Enourage the client's wife to express concerns about making the decision
D. Enourage the client's wife to express concerns about making the decision
Risks within the Healthcare Setting
Medical errors: medication errors, infection, bed sores, and failure to diagnose and treat in time Chemical use Falls Patient-inherent accidents Procedure-related accidents Equipment-related accidents
A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choise are cocaine and heroin. What is the greatest health risk for this client? A. Hepatitis B. Hypertention C. Diabetes D. Glaucoma
D. Glaucoma
A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what interventions should the nurse implement? A. Maintain an oral airway suction equpment and oxygen at the bedside B. Provide respiratory isolation precautions for visitors and staff C. Provide emergency anti convulsant medication at the bedside D. Maintain a quiet calm darkened enviornment
D. Maintain a quiet calm darkened enviornment
elixir
Medication in a clear liquid containing water, alcohol, sweeteners, and flavor
A nurse is caring for a client with Multiple Sclerosis (MS) who is receiving an immunsupressant. Which action is most important for the nurse to implement to evaluate for adverse effects from this particular medication? A. Observe the client's skin for bruising B. Auscultate the client's bowel sounds C. Monitor the clients intake and output D. Note changes in the client's weight
D. Note changes in the client's weight
liniment
Medication mixed with alcohol, oil, or soap, which is rubbed on the skin
A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression devise (SCD) to both lower extremities. (BLE). What action is important when turning the client to a lateral position? A. Decrease the amount of pressure exerted on both legs while turning the client B. Replace the SCD's with an antiembolic stockings while using an abduction pillow C. Remove both of the SCDs while the cient is turned to the lateral position D. Observe the SCDs continue to inflate and deflate when the client is turned
D. Observe the SCDs continue to inflate and deflate when the client is turned
A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take? A. Tell the man when the elevator will see him B. Alert the staff to monitor exits to prevent escape C. Warn the client that he is likely to have a seizure D. Offer a hot meal a clean bed and a sleeping pill
D. Offer a hot meal a clean bed and a sleeping pill
Central Obesity, in a prothrombotic state (prone to clots), proinflammatory state, dyslipidemia, elevated BP 135/85 These people WILL get heart disease & diabetes
Metabolic Syndrome
A nurse is assisting a client from the bathroom back to bed following a minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take? A. Place a cool rag on the client's head B. Suction the client's oral cavity C. Provide the client an emesis basin D. Place the client in a side-laying position
D. Place the client in a side-laying position
____________ changes medications into less active forms or inactive forms by the action of enzymes.
Metabolism (biotransformation)
During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take? A. Withhold any medications that may cause these side effects B. Motivate the client by offering favorite foods as a prize C. Ask the family members to visit more often to stimulate the client D. Record the findings and report the symptoms to the charge nurse
D. Record the findings and report the symptoms to the charge nurse
An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond? A. Review the importance of hygienic measures for improved health B. State that the healthcare provider has prescribed a bath today C. Offer the client several choices of times to bathe during the day D. Request that the client clarify his religious beliefs about bathing
D. Request that the client clarify his religious beliefs about bathing
A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide? A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection
D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection
Which criterion is best for the nurse to use when evaluating a client's response to an analgesic that was administered for postoperative pain? A. Amount of medication required to relieve pain B. Activity without guarding or grimacing C. Objective parameters of blood pressure and respirations D. Subjective score on a 1 to 10 pain scale
D. Subjective score on a 1 to 10 pain scale
The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and teh infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? A. The solution's rate is too rapid B. The client has phlebitis C. The infusion site is infected D. The infusion site is infiltrated
D. The infusion site is infiltrated
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? A. The child looks at the floore when answering the nurse's questions B. The mother's version of the injury is different from the child's version C. The child has several abrasions on the chest and legs D. The mother refuses to answer questions about family history
D. The mother refuses to answer questions about family history
The nurse is monitoring a client with an IV infusion in the left antecubital fossae. The infusion pump is functioning without alarms at the prescribed rate of 100mL/hour. The site is warm, red and without swelling. What conclusion should these findings indicate to the nurse? A. The IV fluids are infusing into the subcutaneous tissues and the pump should be stopped B. The infusion pump is functioning properly and the IV site is healthy C. The insertion date should be verified and the IV discontinued D. The site is inflamed and should be reported to the RN for placement in another site.
D. The site is inflamed and should be reported to the RN for placement in another site.
The scope of practice for the practical nurse includes which client assessments? A. An agitated client with bilateral wrist restraints B. New admission of a client with deep vein thrombosis C. Return of a postaneshesia client following a colon resection D. Transfer of a client with sepsis from a long-term care facility
D. Transfer of a client with sepsis from a long-term care facility
After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is..... A. short of breath after a shower and has a hemoglobin of 8 grams B. Beleeding from a finger stick and has a prothrombin time of 30 seconds C. Febrile and has a WBC count of 14,000/mm3 D. Trembling and has a glucose level of 50 mg/dL
D. Trembling and has a glucose level of 50 mg/dL
Which action should the nurse implement in caring for a client following an electroencephalogram (EEG)? A. Monitor the client's vital signs q4h B. Assess for sensation in the client's lower extremities C. Instruct the client to maintain bed rest for eight hours D. Wash any paste from the client's hair and scalp
D. Wash any paste from the client's hair and scalp
Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status?
Daily body weight
Nociceptive Pain
Damage to bone, soft tissue, or internal organs Usually responsive to nonopioids and/or opioids Types of nociceptive pain: somatic pain and visceral pain
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Correct Answer: D
Augmentin (amoxicillin/clavulante) 500mg suspension is prescribed for an older adult client who has trouble swallowing . The suspension is available in 125mg/5mL solution. How many ml should the client receive? (enter the numberic value only) 500mg/125m X 5mL = 20mL
20
What is regular respiratory rate for a school age child?
20-30
What is a "legally blind" vision?
20/200
A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? 1 Incisional pain 2 Absent bowel sounds 3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing .
3 A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, since this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon
The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Incorrect1 Occipital headache 2 Periorbital crepitus 3 Expectoration of blood 4 Changes in vocalization
3 After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate droplet precautions. 3 Move the client to a private room. 4 Use a high efficiency particulate air (HEPA) respirator during care.
3 Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet, but are not suspended for long periods.
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer
3 Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)
Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.
What hand hygiene should a nurse use after caring for a client with C-Diff
Mild soap hand washing
Patient Safety according to QSEN
Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
pill
Mixture of a powdered drug with a cohesive material; may be round or oval
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit
3 If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. Incorrect2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. Correct3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.
3 Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence
3 Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.
A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? 1 Nursing's Social Policy Statement 2 State law regarding protection of minors 3 ANA Standards of Clinical Nursing Practice 4 References regarding a child's right to consent
3 The ANA Standards of Clinical Nursing Practice guidelines govern safe nursing practice; nurses are legally responsible to perform according to these guidelines. Nursing's Social Policy Statement explains what the public can expect from nurses, but it is not used to govern nursing practice. There are no data that indicate state law regarding protection of minors and references regarding a child's right to consent are necessary.
A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1 Abrasion 2 Fracture 3 Crush injury 4 Incisional laceration
3 The bite of a large dog can exert between 150 and 400 psi of pressure, causing a crush injury. A crush injury may or may not include a fracture. Abrasions and incisional lacerations are not caused by this form of trauma.
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1 Respiratory rate. 2 Amount of oxygen in the blood. 3 Percentage of hemoglobin-carrying oxygen. 4 Amount of carbon dioxide in the blood
3 The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties
3 With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.
Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Incorrect 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli .
3,4 Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias
3,4,5 Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness
3,5 Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia, bradycardia is.
What are the indications for NG tube?
Decompression, feeding, lavage, compression
Which stage of sleep is the deepest sleep?
NREM stage 4
somatic pain
Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves.
verbal communication
Depends on language or a prescribed way of using words so that people can share information effectively Ex. -written -spoken -television and radio -movies -magazines -books -computers -posters -brochures
CRIES pain scale
Neonates (ages 0-6 months)
Violations that may result in disciplinary actions Scope of practice
Newly hired nurses in a busy suburban hospital are required to read the state Nurse Practice Act as part of their training. Which topics are covered by this act? Select all that apply.
Oxygen Saturation
Normal PaO2 80-100 mm Hg Normal O2 saturation > 95% (SaO2) Compare to pulse oximetry reading (SpO2)
What is a regular respiratory rate for a newborn?
30-60
The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number) 75mL X 15gtt/mL = 38
38
An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute.
38 Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute
planning
3rd step of nursing process; a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.
4
A health care provider prescribes 10 mL of a 10% solution of calcium gluconate for a client with a severely depressed serum calcium level. The client also is receiving digoxin (Lanoxin) 0.25 mg daily and an intravenous (IV) solution of D5W. The nurse's next action is based on the fact that calcium gluconate: 1 Can be added to any IV solution Incorrect2 Must be administered via an intravenous piggyback (IVPB) 3 Is non-irritating to surrounding tissues Correct4 Potentiates the action of the digoxin preparation
4 Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate cannot be added to a solution containing carbonate or phosphate because a dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the client is receiving. If calcium infiltrates, sloughing of tissue will result.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable
4 A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)
4 Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 1 4 to 8 hours 2 12 to 24 hours 3 24 to 48 hours 4 72 to 96 hours
4 Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance
4 Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? 1 Prolonged use can cause dark concentrated urine. 2 The medication is best absorbed when taken on an empty stomach. 3 Take the medication with aluminum hydroxide to minimize GI upset. 4 Drinking alcohol daily can cause drug-induced hepatitis
4 Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.
When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty 4 False imprisonment
4 False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? 1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. 4 The antigen is neutralized by the antibodies that it supplies
4 Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression 4 Acceptance
4 In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall
4 Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention
A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1 Ask the client if he is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe
4 Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought
4 The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal basis, and the nurse may be held liable.
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1 Sodium 2 Calcium 3 Chloride 4 Potassium
4 The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site
4 This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? 1 Vitamin A (Aquasol A) 2 Cyanocobalamin (Cobex) 3 Phytonadione (Mephyton) 4 Ascorbic acid (Ascorbicap)
4 Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress
4 When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.
NCLEX Question: a nursing instructor reviews the goals of Healthy People 2020 with students. Which statement by a nursing student indicates a need for further education? 1) "I know that nurses are key to the health indicator - Clinical Preventative Services." 2) "I would like to know more about the ways nurses can improve access to health services." 3) "I will study the Healthy People 2020 to learn more about how these indicators work." 4) "I know that nurses have a limited impact on the health indicators."
4) "I know that nurses have a limited impact on the health indicators."
Example of a directing question
Nurse: You mentioned your dad earlier. Did he develop complications related to high blood pressure? Patient: Yes. Nurse: What sort of complications? Patient: Kidney failure. He was on dialysis for years before getting a transplant. Nurse: Are you afraid this might happen to you?
A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? 1 Monitor the client's pain level for another hour. 2 Determine the integrity of the intravenous delivery system. 3 Reprogram the pump to deliver a bolus dose every eight minutes. 4 Arrange for the client to be evaluated by the health care provider.
Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.
Which technique should the PN nurse use to give a Z-track IM injection?
Inject the med into the dorsal gluteal site
Mild anxiety symptom
Insomnia
Objective nursing assessment as related to oxygenation
Inspection, Palpation, Percussion, Auscultation; Laboratory and diagnostic tests Hemoglobin Pulse oximetry Arterial blood gases
When irrigating the external ear canals of an older adult client, which action should the PN use to soften dry cerumen for removal?
Instill mineral oil in the external auditory canal overnight before irrigation.
implementation
4th step of nursing process; formally begins after the nurse develops a plan of care
Where is the point of maximal impulse of the heart?
5th ICS at MCL left of the sternum
When do early symptoms of alcohol intoxication and withdrawal appear?
6-12 hours after last drink
What are the qualifications for medicare?
65+ 10 year record in medicare covered employment under 65 with end stage renal disease or totally disabled
How many mL should the nurse document when calculating a client's 8-hour fluid intake? (Enter the numeric value only.) 0730 - 4 ounces of orange juice, hardboiled egg, and toast 1130 - 1/2 cup of soup, one half sandwich, and 1/2 cup of apple juice 1300 - vomitus of 100 mL 1400 - voided 250 ml and consumed one 12-ounce can of soft drink (type your answer in the box below) 1oz = 30mL; so 4oz of orange juice X 30mL = 120mL of orange juice Then 1 cup = 240; so ½ cup is 120mL of soup and ½ cup of apple juice is 120mL of apple juice = 240mL total vomitus is output, not intake, so ignore voided is output, not intake, so ignore 1 oz = 30mL; so 12oz is 12oz X 30mL = 360mL add them all; 120mL + 240mL + 360mL = 720mL
720
The nurse is giving medications to a client who was admitted to the hospital with a diagnosis of Diabetes Mellitus Type II. After checking the finger stick glucose at 1630dL, what dose of insulin should the nurse administer? (enter the numeric value only) (Click on each chart tab for additional information. Please be sure to scroll to the bottom-right corner of each tab to view all information contained in the client's medical record.)
8
How big should the bladder of a BP cuff be?
80% the circumference of the arm of an adult and the whole arm of a child
What is the average pulse rate for a 12-14 year old
80-90
ICN =
International Council for Nurses
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.
A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated. Correct Answer: B
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.
A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred. Correct Answer: D
SBAR
A hand-off communication method that provides consistent communication that is clear structured, and easy to use. Recommended by the Joint Commission and Institute for Healthcare Improvement in an effort to eliminate breakdowns in communication and potential adverse events. -*S*ituation -*B*ackground -*A*ssessment -*R*ecommendations
Nonmaleficence
A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accordance with which of the principles of bioethics?
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B
What oxygen mask delivers the highest concentration of oxygen?
A non rebreather mask
An incident report is used as a means of identifying risks. An incident report is used for quality control. An incident report makes facts available in case litigation occurs.
A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe aspects of this procedure? Select all that apply.
Values act as standards to guide behavior. Values are ranked on a continuum of importance. Values influence beliefs about health and illness.
A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe a characteristic of the development of a personal value system? Select all that apply.
The science of nursing
A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral aneurysm following a loss of consciousness in the emergency room. The nurse anticipates preparing the patient for ordered diagnostic tests. This nurse's knowledge of the diagnostic procedures for this condition reflects which aspect of nursing?
Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy
A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?
A patient shows off a new outfit that she is wearing after losing 20 pounds. A patient proudly displays his certificate for completing a marathon.
A nurse who is working in a hospital setting after graduation from a local college uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply.
Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse.
A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true?
Promote universal access to health
A professional nurse with a commitment to social justice is most apt to:
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.
A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care. Correct Answer: C
Criminal law
A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law?
Palliative care
A switch from curative treatment to comfort measures
enteric coated
A tablet or pill coated to prevent stomach irritation
Iatrogenic Infection
A type of HAI from a diagnostic or therapeutic procedure.
Following a cholecystectomy, a client ask the PN about dietary restrictions that may need to be followed. Which diet should the PN recommend?
A well balanced diet with no other restrictions
What's a tort?
A wrong committed by a person against another person or property; tried in civil court.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.
Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority. Correct Answer: C
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.
A) Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
A) Be sure to have a complete physical examination before beginning your planned exercise program The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A).
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records
A) Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF
A) Commend the client for selecting a high biologic value protein Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.
A) Determine the etiology of the problem Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders.
A) Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems (B), so it is not a reason to seek health care (C). A genogram is not a diagnostic tool to detect disorders (D), such as those based on pathological findings or DNA.
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A) It is important that you continue your medication while learning to meditate. B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C) Obtain your healthcare provider's permission before starting meditation. D) Complementary therapy and western medicine can be effective for you.
A) It is important that you continue your medication while learning to meditate The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured
During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry.
A) Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery?
A) What is your daily calorie consumption? Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference
The nurse is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? A. 17-year-old who is sexually active simultaneously with numerous partners B. 34-year old homosexual who is in a monogamous relationship C. 30-year-old cocaine user who inhales and smokes drugs D. 45-year-old who has received two blood transfusions in the past 6 months
A. 17-year-old who is sexually active simultaneously with numerous partners
After a change of shift report, the nurse makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the nurse? A. A client who is having bright red drainage from the rectum following a colonoscopy with a polyp removal B. A client who has pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy C. An older client whose blood pressure is 100/70 after receiving meperidine for pain related to a hip fracture D. A client who has brown green bile draining froma T-tube after a cholecystectomy for Cholelithiasis.
A. A client who is having bright red drainage from the rectum following a colonoscopy with a polyp removal
The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD? A. Anemia B. Anuria C. Hypotension D. Edema
A. Anemia
The nurse assumes care of a client who was admitted earlier in the day for a scheduled Hysterectomy in the morning. Which recorded assessment data obtained by the admitting registered nurse is objective? (Select all that apply). A. Anemia B. Menorrhagia C. Tiredness D. Orthostatic hypotension E. Fear F. Nervousness 205. The nurse empties
A. Anemia, D. Orthostatic hypotension
A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make? A. Ask for a description of what happened during the night B. Tell the daughter to talk to the unit's nurse manager C. Reassure the daughter that the mother will get better care. D. Explain that all the staff are doing the best they can.
A. Ask for a description of what happened during the night
The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take? A. Ask the client why the bath was refused B. Ask family members to encourage the client to bathe C. Explain the importance of good hygiene to the client D. Reschedule the bath for the following day
A. Ask the client why the bath was refused
A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? A. Autonomy vs. Shame and doubt. B. Industry vs. Inferiority C. intiative vs. Guilt D. Trust vs. Mistrust
A. Autonomy vs. Shame and doubt.
The nurse is reviewing the discharge medication instructions with a client for disulfiram 10mg (Antabuse). Which instruction should the PN reinforce with the client? A. Avoid all sources of alcohol while taking this drug including cough syrups B. The medication should be taken at the same time each day C. Stop the drug if nausea, vomiting and/or prostration occur D. Have weekly blood tests to determine therapeutic drug levels and serum sodium
A. Avoid all sources of alcohol while taking this drug including cough syrups
The nurse is emptying the bedpan of a client with a bleeding gastric ulcer. What type of stool can the nurse expect this client to have. A. Black tarry stool B. Coffee-ground stool C. Bright red bloody stool D. Clay-colored stool
A. Black tarry stool
The nurse is receiving a client following an emergency Cesarean Section (C-Section). Which information is most important for the nurse to obtain? A. Blood pressure and pulse rate B. Gravida and parity C. Medications received during labor D. Temperature and respiratory rate
A. Blood pressure and pulse rate
What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? A. Cleanse the radiated area with water and pat the skin dry B. Lightly massage the radiated skin with a lanolin-based lotion C. Rinse the site with normal saline and cover with a sterile towel D. Use of soft washcloth to gently remove the skin markings
A. Cleanse the radiated area with water and pat the skin dry
A client asks the nurse to explain the location of the prostate gland. What is the best response? A. Close the rectal wall the prostate gland sits behind the symphysis pubis extending around the beginning of the urethra B. At the bottom of the scrotal sac, the prostate gland rests beneath the testes, held in place by the spermatic fascia C. Attach to the front and sides of the pubic arch, the prostate is a mess of cavernous tissue held together by fibrous tissue D. Located at the lateral edge of the posterior segment of the testes, the prostate creates a bulge continuous with the vas deferens
A. Close the rectal wall the prostate gland sits behind the symphysis pubis extending around the beginning of the urethra
The nurse is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate? A. Conversion of irregular heart rate to regular heart rhythm B. Pulse oximetry readings within normal range during activity C. Peripheral pulse points with adequate capillary refill D. Increase excercise tolerance without shortness of breath
A. Conversion of irregular heart rate to regular heart rhythm
The nurse is administering multiple medications to a 78-year-old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make? A. Cumulative serum drug levels and toxicity B. Synergistic actions due to simultaneous administration C. Tolerance to drugs that have been taken for long periods of time D. Antagonist actions of multiple medications
A. Cumulative serum drug levels and toxicity
The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging, increases the elderly client's risk of having an adverse response to the medication? A. Decreased gastrointestinal motility B. Poor cognitive function C. Poor peripheral circulation D. Decreased mobility
A. Decreased gastrointestinal motility
An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that this client is exhibiting which signs or symptom? A. Delusions of persecution B. Ideas of reference C. Hallucinations D. Confabulation
A. Delusions of persecution
Which intervention is within the scope of practice for a nurse? A. Demonstrating deep breathing and coughing to postoperative client B. Teaching the use of glucometer to a newly diagnosed diabetic client C. Presenting support options that are available to those with cancer D. Discharge teaching about newly prescribed medications
A. Demonstrating deep breathing and coughing to postoperative client
A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan? A. Drink 3 quarts of water daily B. Avoid swimming in public pools C. Avoid intercourse until all antibiotics have been taken D. Drink 3, 6-ounce cans of cranberry juice daily
A. Drink 3 quarts of water daily
In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client? A. Empty and measure the drainage in the suction drainage device B. Reassure the client that phantom limb pain is genuine pain C. Review the client's vital signs for indications of infection D. Observe and mark the amount of drainage on the dressing
A. Empty and measure the drainage in the suction drainage device
The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpfull in preventing further development of the decubitus? A. Encourage the client to eat foods high in protein B. Assess the client with daily range of motion exercises C. Teach the family how to perform sterile wound care D. Ensure the IV fluids are administered as prescribed
A. Encourage the client to eat foods high in protein
A terminally ill male client and his family are requesting hospice care after discharge from the hosptial and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? A. Enhance symptom management to improve end of life quality B. facilitates assisted suicide with the client's consent C. Offers ways to postpone the death experience at home D. Provide training for family members to care for the client.
A. Enhance symptom management to improve end of life quality
A client is adminitted to the hosptial with a diagnosis of Pneumonia. Which intervetion should the nurse implement to prevent complications associated with Pneumonia? A. Enourage mobilization and ambulation B. Encourage energy conservation with complete bed rest C. Provide humidified oxygen per nasal cannula D. Restrict PO and intravenous fluids
A. Enourage mobilization and ambulation
An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath sounds frequently. What other intervention should the nurse implement related to the client's decreased vital capacity? A. Evaluate pulse oxygen saturation B. Allow extra education time C. Encourage high protein supplements D. Monitor intake and output
A. Evaluate pulse oxygen saturation
An obese female client with a high serum cholesterol level comes to the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the nurse to provide? A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels B. Discuss the importance of maintaining a target heart rate during each excercise period C. Teach the client additional ways to lower cholesterol, including stress management D. Praise the client for her excercise and dieting efforts and encourage her to continue with this program
A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels
A client's chief complaint is being able to swallow only small bites of solid food and liquid's for the last 3 months. The nurse should assess the client for what additional information? A. History of alcohol and tobacco use B. Average daily consumption of hot beverages C. Past traumatic injury to the neck D. Daily dietary roughage intake
A. History of alcohol and tobacco use
What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling catheter (Foley)? A. Keep the catheter intact while assisting the client with a shower B. Remove the catheter while the client takes a shower C. Provide the client with a sponge bath in a chair or the bed D. Assist the client with a tub with the catheter clamped
A. Keep the catheter intact while assisting the client with a shower
Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary incontinence? A. Maintain standard precautions B. Utilize an antibacterial perineal wash C. Insert an indwelling urinary catheter D. Initiate contact isolation precautions
A. Maintain standard precautions
A 3 year-old admitted with fever of unknown origin (FUO) has begun vomiting in the past half hour. The child's temperature is 101.80 F, and the last dose of antipyretic medication was given 5 hours ago. The child has prescriptions of acetaminophen (Tylenol) 160 MG per 5 mL elixir or 160 mg suppositories PRN fever or pain. What action should the nurse take at this time? A. Make the child NPO and hold all medications untill the vomiting has stopped B. Give acetaminophen elixir to ensure the child's cooperation with swallowing C. Notify the healthcare provider that the child's fever has become dangerously high D. Use an acetaminophen suppository for the fever since the child is vomiting
A. Make the child NPO and hold all medications untill the vomiting has stopped
After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-pound weight loss from the pre-dialysis weight. The client reports feeling weak and fatigued. What action should the nurse take next? A. Measure the client's blood pressure B. Auscultate the client's breath sounds C. Observe the client's legs for edema D. Determine the client's blood glucose
A. Measure the client's blood pressure
A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects? A. Moon face, Slow wound healing, muscle wasting sodium and water retention B. Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbital edema D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
A. Moon face, Slow wound healing, muscle wasting sodium and water retention
A client receives a new prescription for the angiotensin II receptor antagonist losartan (Cozaar). Which client instruction should the nurse encourage this client to follow? A. Move slowly when getting up to prevent sudden dizziness B. Take this medication with or after meals C. Do not stop this medication until all of the tablets are gone D. Keep the dietary log during initial therapy
A. Move slowly when getting up to prevent sudden dizziness
The nurse plans to assess a newborn and to check the infant's Moro reflex. In assessing this reflex, the nurse is evaluating which parameter? A. Neurological integrity B. Renal functioning C. Thermogenic regulation D. Respiratory adequacy
A. Neurological integrity
The nurse is caring for a 10-year-old child with hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurst take when interacting with the child and mother? A. No special precautions are needed B. Wear gloves only C. Wear gloves and a mask D. Wear a mask, gloves and gown.
A. No special precautions are needed
A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT feedings? A. Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings B. Flush the GT with 50mL of water and clamp the GT to prevent leakage C. Place the infant in the right lateral position to facilitate gastric emptying D. Burp the infant after each 10mL of formula administration and re-feed any volume that is spit up
A. Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings
A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine. He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse implement? A. Offer the client a full glass of water B. Give medications 2 hours apart C. Provide a snack with the medications D. Administer only the docusate sodium
A. Offer the client a full glass of water
A client complains of kidney pain. The nurse understands that the kidneys are located where? A. On the retroperitoneal posterior abdominal wall at the costovertebral angle B. Within the curve of the duodenum, posterior to the spleen C. Lateral to the stomach in the hypochondriac region D. Superior aspect of the bladder in right and left iliac region
A. On the retroperitoneal posterior abdominal wall at the costovertebral angle
At 7AM, a Diabetic client is conscious with a serum glucose level of 50mg/dL. To manage this client's care effectively, what should the nurse administer? A. Orange juice B. Glucagon C. 10 units of regular insulin d. IV of 5% glucose in water at 100 mL/hr
A. Orange juice
A client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the nurse to include in this client's record? A. Pedal pulses, pallor, pain, paresthesia or paralysis B. Level of consciousness, lung sounds, and bladder tone C. Swallow reflex, nausea, and vomiting and IV infusion rate D. Call bell side rails, bed in position, and ambulation aids
A. Pedal pulses, pallor, pain, paresthesia or paralysis
An 82-year old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to... A. Prevent foot drop B. Prevent hip dislocation C. Promote moving in bed D. Promote early ambulation
A. Prevent foot drop
A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of tuberculosis (TB)? A. Proper disposal of tissues when coughing B. Importance of an adequate diet C. Complication sof the disease D. Side effects of anti-tubercular medications
A. Proper disposal of tissues when coughing
The nurse should recommend that males over the age of 45 obtain which test to screen for prostatic cancer? A. Prostate-specific antigen (PSA) B. Alpha-fetoprotein radio immunoassay (AFP) C. Ultrasound of the scrotum D. Serum testosterone level
A. Prostate-specific antigen (PSA)
A nurse sees a colleague taking drugs from the hospital unit. What action should the nurse take? A. Report the incident to the person in charge of the unit or Nursing supervisor B. Notify the hospital security staff to retrieve the drugs from the colleague C. Report the colleague to the peer review committee of the hospital D. Confront the colleague and tell him/her to take the drugs back to the unit
A. Report the incident to the person in charge of the unit or Nursing supervisor
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not rising. What action should the nurse take first? A. Reposition the head to ensure an open airway B. Inflate the lungs with more breaths and air pressure C. Finger sweet for a foreign body lodged in the oral cavity D. Reposition hands on chest continue compressions
A. Reposition the head to ensure an open airway
The nurse is caring for an elderly client who has suddenly become confused after 2 days of vomiting and diarrhea. What laboratory result should the nurse report first to the RN? A. Serum potassium 6mEq/L, serum sodium 126mnEq/L, and serum chloride 115mEq/L B. Glucose tolerance results fasting 80 mg/dL, 1hr: 110mg/dL 2hr: 120 mg/dL, 3hr: 90 mg/dL C. Negative Hepatitis B Surface Antigen, serum total biilirubin 0. 1 mg/dL D. Troponin l < 0.1ng/mL and creatinine kinase MB (CK-MB) 2% of total 10 milliunits/L
A. Serum potassium 6mEq/L, serum sodium 126mnEq/L, and serum chloride 115mEq/L
The nurse is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? A. Smokes one pack of cigarettes daily B. Drinks two beers daily C. Works in a job that requires exposure to the sun D. Eats while lying in bed
A. Smokes one pack of cigarettes daily
A client is complaining of muscle fatigue in the lower extremities. What is the physiological cause of muscle fatigue? A. The depletion of glycogen and energy stores B. Electrical stimulus failure at the neuromuscular junction C. Calcium concentration decrease in the muscle sarcomere D. Hyperoxygenation of the muscle fiber
A. The depletion of glycogen and energy stores
An elderly female client tells the nurse that she does not do regular Breast Self Examinations (BSE) because she is too old. The nurse's response to the client is based on what information? A. The incidence of breast cancer increases with age B. The client should have a health care provider do a breast exam at least once a year C. After age 70, breast cancer is less likely to occur D. The history of breast cancer in a family member is indicative of the need for BSE
A. The incidence of breast cancer increases with age
A Client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture? A. The neck extended backward using a rolled towel behind the neck B. Prone position using pillows to support both arms outward from the torso C. Side-lying position using pillows to support the abdomen and back D. The neck forward using pillows under the head and sandbags on both sides
A. The neck extended backward using a rolled towel behind the neck
A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer? A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack B. The space around your heart is filling with fluid and your healthcare provider will have to explain the treatment C. The heart cells have been infiltrated by organisms and a secondary autoimmune reaction has occurred D. This is an infection of the lining of the heart caused by bacteria entering through your gums
A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack
A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped B. They should wait to resume sexual activities until the fatigue assorted with a new baby has passed C. They can resume sexual activity at 6 weeks postpartum D. It is best to wait until both parties feel up to having sexual intercourse
A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped
When providing oral care to an unconscious client who is a mouth breather and does not swallow, which action is most important for the nurse to implement? A. Use an oral suction catheter in the buccal cavity B. Inspect the oral cavity using gloves fingers C. Perform oral cleansing with a sponge toothette D. Apply a petroleum based lubricant to the client's lips
A. Use an oral suction catheter in the buccal cavity
The nurse is preparing to administer a 1.2mL injection to a 4-year-old. Which are the best sites to administer an IM injection? Select all that apply. A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Rectus femoris E. Deltoid
A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal
The nurse is caring for a mother who is bottle-feeding and develops breast engorgement. Which intervention is most effective in reducing breast engorgement? A. Wearing a tight-fitting bra B. Applying hot packs to the breasts C. Expressing milk from the breast by hand D. Exposing the breasts to air
A. Wearing a tight-fitting bra
Need to know in Patient Safety
Developmental levels Mobility, sensory, and cognitive status Lifestyle choices Special risks found in health care setting
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.
Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). Correct Answer: A
An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the PN that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first?
Digitally assess for impacted stool.
When irrigating the eyes of a client, which action should the PN implement?
Direct the irrigation flow from the inner canthus to the canthus of the affected eye.
The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus)
Duration of Insulin is:
An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast. Which cereal should the nurse provide? A. Corn flakes B. Granola C. Oatmeal D. Wheat puffs E. Rice
E. Rice
In planning care for an older client on bed rest, which intervention should the PN include in the prevention of pressure ulcers?
Elevate the HOB less than 30 degrees
An older female recently diagnosed with coronary artery diesel cooks at home using saturated fats. Which intervention should the PN implement to help the client reduce modifiable risk factors?
Encourage food preparation with various vegetable oils
An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy to the PN to implement for the clients incontinence?
Establish a 2 hour voiding schedule
The PN is obtaining information for a male clients psychosocial assessment. Which action should the PN implement first?
Establish a therapeutic relationship
Which time frame should the PN res position a client?
Every 2 hours
How often do you need to get a new rx for restraints on an adult?
Every 4 hours
If a patient is using an ice/heat therapy, how often should you assess the site?
Every 5-10 minutes
How often do you need to get a new rx for restraints on a pt younger than 9 years old?
Every hour
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.
Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated. Correct Answer: B
Pain Assessment
Factors influencing the pain experience: Location Intensity Quality Pattern Aggravating/relieving factors Medication history
SPICES Framework
Factors that affect a patients mobility; the presence of these conditions can lead to increased death rates, higher costs, and longer hospitalizations for older clients. These conditions are common, preventable, and signal a need for a more in-depth assessment -*S*leep disruption -*P*roblems with eating and feeding -*I*ncontinence -*C*onfusion -*E*vidence of falls -*S*kin breakdown
Error Defined
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
What is healthy people 2020?
Federal government indicative. Sort of like "Guidelines" for the US health standards.
Adolescent PT plan of care with bacterial infection
Fever- blood cultures
Place each step of the nursing process in the order that it should be used. Correct 1. Obtain client's nursing history. Correct 2. State client's nursing needs. Correct 3. Identify goals for care. Correct 4. Develop a plan of care. Correct 5. Implement nursing interventions.
First the nurse should gather data. Based on the data, the client's needs are assessed. After the needs have been determined, the goals for care are established. The next step is planning care based on the knowledge gained from the previous steps. Implementation follows the development of the plan of care.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.
First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Correct Answer: B
Who is the founder behind the profession of nursing?
Florence Nightingale
An older client who is unable to swallow is receiving continuous NGT feeding. Before administering medications through the NGT, what action should the practical nurse implement?
Flush the feeding tube with water.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.
Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary. Correct Answer: A
Stage 3 pressure ulcer
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
Stage 4 pressure ulcer
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
When should you withhold an enteral feeding and call MD?
Gastric residual >250ml x2 assessments, diarrhea, N/V, Aspiration
subset of type 2 due to hormone release from placenta resist insulin 2nd & 3rd Trimester, give glucose challenge, dx if over 126
Gestational Diabetes
Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Correct Answer: C
What are the steps of the nursing process?
ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE -DOCUMENT-
Neuropathic Pain
Abnormal processing of sensory input by the peripheral or central nervous system; Treatment usually includes adjuvant drugs; A physical cause for reports of excruciating pain may not be evident on examination
____________ is the transmission of medications from the location of administration (gastrointestinal tract, muscle, skin, or subcutaneous tissue) to the bloodstream.
Absorption
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.
Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings. Correct Answer: C
In a nutshell, the ICN's key values of nursing are:
Advocacy, promotion of a safe environment, research, education, and participation in shaping health policy and in patient and health systems management.
Serum Potassium
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.
All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Correct Answer: D
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D). Correct Answer: A
Nursing Care Infection Control-wound care
Handwashing Use gloves Elevate foot Aseptic technique for dressing change Discard contaminated dressing, linens, etc. properly Administer medications Management of fever Rest Maintain glucose within normal range Healthy diet Teach infection control
How do you perform the romberg test, and what is it looking for?
Have the client stand with their feet together and arms at their sides. It measures stability with and without eyes closed.
What four things determine cardiac output?
Heart rate, contractility, blood volume, venous return
Diagnostic Tests as related to oxygenation
Hemoglobin Levels: 13.5-18g/dl males, 12-16g/dl female Chest x-ray Pulmonary function studies Lung Scan Bronchoscopy Throat culture Sputum specimens Pulse oximetry
Which action should the practical nurse implement to help a male client cope with his fear as he approaches death?
Hold the client's hand and tell him he is no alone.
A client who has pressure relieving mattress overly is mobilized to a chair and imprints of the client buttocks, heels, and scapula are evident on the mattress overlay. What action should the PN implement?
Apply a different pressure relieving device and assess its effectiveness for this client
Somatic Pain
Arises from bone, joint, muscle, skin or connective tissue Usually aching or throbbing in quality and is well localized
A male client is upset with the healthcare providers recommendation that he should consent to an above-knee amputation. He tells the PN, "If they want to cut off my left, they should just shoot me instead." How should the PN respond?
As the client how the surgery might effect his lifestyle
How do you check placement of an NG tube?
Aspirate content and check pH (ph should be 4) X-Ray
What action should the PN take when drawing meds from an ampule?
Aspirate with a filter needle and syringe.
Pharmacological Measures Nursing Responsibilities (pain management)
Assess pain Determine when to administer analgesics Select the appropriate analgesic Evaluate effectiveness of analgesics Monitor and manage medication side effects Suggest changes Consider the needs of special populations (mentally ill, cognitively impaired, etc)
Role of nurse in infection control
Assess patient's defense mechanisms: age, nutritional status, stress, disease process; susceptibility and knowledge of infections; "Risk for Infection": lab data and clinical appearance; Consult Infection Control Practitioner: clients with infection
physical examination for fall risk
Assess: -mobility status -ability to communicate -level of awareness or orientation -sensory perception -identify potential safety hazards -recognize manifestations of domestic violence or neglect
A male client ho is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." Which action should the PN implement first?
Assist the client to a supine position.
Acls and cpr asap!
Asystole
How often should you clean a urinary catheter?
At least 3 times a day and after defecation
Alterations in Respiratory Functioning
Atelectasis Aspiration Hyperventilation Hypoventilation Hypoxia
general nursing actions in regards to oxygenation
Auscultate lung sounds - Monitor RR, depth, rhythm -Monitor vital signs -Monitor O2 sat, ABGs -Monitor mental status -Position for best lung expansion, elevate HOB -Reposition regularly -Ambulate patient -Provide oxygen -Provide humidification -Increase fluid intake -Ensure adequate diet -Provide good oral hygiene -Provide emotional support -Utilize incentive spirometry -Administer medication -Provide education -Prevent and recognize complication
Nonmaleficence =
Avoid causing harm
A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report? A. Decreased sexual libido B. Amenorrhea C. Quickening D. Nocturia
B Amenorrhea
What is the ICN definition of nursing?
Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, & communities, sick or well in all settings.
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets.
B) 1 tablet 15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B).
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.
B) 1.5 ml
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A) 13 ml/hour. B) 63 ml/hour. C) 80 ml/hour. D) 125 ml/hour
B) 63 ml/hour
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.
B) 8 a.m., 4 p.m., and midnight Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure
B) A decreased flow rate could result in the formation of a thrombosis Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer.
B) A lactating woman nursing her 3-day-old infant A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.
B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation
B) During the inhalation The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C).
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.
B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) prone. B) Fowler's. C) Sims'. D) supine
B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration
Which intervention should the PN use to prevent obstruction of a gastric feeding tube?
Obtain a prescription for a liquid drug form instead of crushing tablets.
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses
B) Initiate an alternate site for the IV infusion of the medication A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D).
The practical nurse is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement?
Obtain a soft-bristle brush for the client.
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors
B) Nutritional history Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A) Irrigate the nasogastric tube with sterile normal saline. B) Reposition the client on her side. C) Advance the nasogastric tube an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use.
B) Reposition the client on her side The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet
B) Upper torso The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. B) often follows relocation to new surroundings. C) is a result of irreversible brain pathology. D) can be prevented with adequate sleep
B) often follows relocation to new surroundings Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion
A nurse is caring for a client that has been prescribed potassium. The client says the pill is too large and refuses to take it. The nurse offers to break it into two smaller pieces. The nurse is demonstrating which ethical principle? A. Autonomy B. Beneficence C. Justice D. Nonmalificence
B- Beneficence
The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "what do these letters T1N0M0, stand for?" which response should the nurse provide first? A. "The letters are used to predict the prognosis of the cancer or tumor." B. "The letters stand for tumor size, node involvement and metastasis." C. "Let me refer you to the charge nurse." D. "Are you confused? Would you like to talk?"
B. "The letters stand for tumor size, node involvement and metastasis."
Which pediatric client is most likely to experience a disturbed body image? A. 10-year-old with plantar warts B. 14-year-old with acne vulgaris C. 16-year-old with a perineal tinea infection D. 12-year-old with bacterial cellulitis
B. 14-year-old with acne vulgaris
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A) 42 gtt/min. B) 83 gtt/min. C) 125 gtt/min. D) 250 gtt/min
B. 83 gtt/min
The nurse is assessing care for residents on a 12-bed unit in an extended care facility. The staff consists of 1 unlicensed assistive personnel (UAP) and 1 certified medication aide. Which task should the nurse perform? A. Ambulate the client who has left hemiplegia and uses a cane B. Administer medications and formula to a client with a gastronomy tube C. Change a hydrocolloid dressing for a client with a stage II pressure ulcer D. Provide self-catheterization equipment for a client with paraplegia
B. Administer medications and formula to a client with a gastronomy tube
The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical excercises with the physical therapy department? A. Before bedtime, at 2000 B. After breakfast C. Before the evening meal D. After lunch
B. After breakfast
A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA). The nurse anticipates implementing care for which client problem? A. High risk for injury B. Altered breathing patters C. Ineffective airway clearance D. High risk infection
B. Altered breathing patters
The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action? A. Confirm the room and bed numbers with those on the medication record B. Ask a regular staff member to confirm the residents identity C. Hold the medication untill a family member arrives D. Re-orient the resident to name, place and situation.
B. Ask a regular staff member to confirm the residents identity
An adult female client is admitted to the psychiatric unit with diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement? A. Tell the client to keep her belongings because she will need them at discharge B. Ask the client if she has had any recent thoughts of harming herself C. Reassure the client that the antidepressant drugs are apparently effective D. Support the client by telling her what wonderful progress she is making.
B. Ask the client if she has had any recent thoughts of harming herself
In assisting a client perform pursed lip breathing, the nurse should ensure that the client performs which action? A. Inhale through the nose with the mouth shut and exhale through pursed lips B. Inhale through pursed lips then exhale with the mouth held open C. Inhale through pursed lips and then exhale through the nose with the mouth closed D. Inhale through the mouth puff the cheeks and exhale through pursed lips
B. Ask the client if she has had any recent thoughts of harming herself
Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the nurse. After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a Semi-Fowler's position. However, the nurse meets resistance and the clients voicees discomfort. What action should the nurse take next? A. Attempt to withdraw additional fluid from the balloon B. Assist the client in taking a series of deep breaths C. Lower the head of the client's bed so the client is supine D. Allow the client to rest before continuing to remove the catheter
B. Assist the client in taking a series of deep breaths
The nurse is taking blood presure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position? A. Slightly above the level of the heart B. At the level of the heart C. At the level of comfort for the client D. Below the level of the heart
B. At the level of the heart
The nurse identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the nurse? A. Heart rate increases of 10 beats per minute B. Bowel movements decrease to 1 every third day C. Urinary output decreases of 250mL in the last 24 hours D. D. Systolic blood pressure decrease of 10mmHg
B. Bowel movements decrease to 1 every third day
Which structure of the tracheobronchial tree is the most likely to compromise air passage when the smooth muscle layer is affected? A. Secondary bronchi B. Bronchioles C. Segmental bronchi D. Alveolar ducsts
B. Bronchioles
A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the client to manifest in response to the administration of this drug during an acute anginal episode? A. Pulse oximetry within normal limits B. Cessation of acute chest pain C. Hypertension and headache D. Premature ventricular contractions (PVC)
B. Cessation of acute chest pain
A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? A. Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations B. Change the Pleur-Evac system and re-assess output in the empty chamber C. An increase in the prescribed suction force to facilitate-drainage of serosanguineous fluids D. Advance the chest tube to ensure proper placement of the tip to enhance drainage
B. Change the Pleur-Evac system and re-assess output in the empty chamber
A client is admitted with a fever of undermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first? A. Change the bed linen to prevent chilling B. Check the client's vital signs and pain scale C. Assess the client for urinary incontinence D. Determine fluid intake for the past 8 hours
B. Check the client's vital signs and pain scale
The nurse in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who i shelping with the care of several clients? A. Measure the amount of a client's residual urine after voiding B. Cleanse the perineal area of a client with urinary incontinence C. Insert a straight catheter to obtain a urine specimen for culture D. Provide catheter care for a client with a suprapubic catheter
B. Cleanse the perineal area of a client with urinary incontinence
A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention will the nurse implement first? A. Auscultate the client for bowel sounds and ability to urinate B. Determine the amount of water and exact time it was taken C. Notify the healthcare provider of the client's fluid intake D. Reassure the client that a small amount of water is not harmful
B. Determine the amount of water and exact time it was taken
While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fuity odor. What assessment should the nurse perform first? A. Auscultate the client's bowel sounds B. Determine the client's capillary glucose C. Observe the color of the client's urine D. Measure the client's oxygen saturation
B. Determine the client's capillary glucose
The nurse is standing at the clinic desk when a mother and preschool child approach. The mother tells the nurse that her child has a fever and rash. What action should the nurse take? A. Take the child immediately to a different part of the clinic B. Have them wait in the waiting area away from the other children C. Tell the mother to return to the clinic when the rash subsides D. Place them first on the list to see the healthcare practitioner
B. Have them wait in the waiting area away from the other children
The nurse observe that the IV catheter is no longer in a client's arm. It is on the bed, and the sheets are moist with IV fluid. The client is disoriented and states he does not remember pulling the catheter out. How should the nurse document this situations? A. Client does not remember pulling out the IV B. IV catheter found lying on bed sheets C. IV catheter pulled out by disoriented client D. IV discontinued and wet sheets changed
B. IV catheter found lying on bed sheets
Which technique should the nurse use to give a Z-track intramuscular injection? A. Ensure that no air is present in the syringe B. Inject the medication into the dorsal gluteal site C. Select a 22-gauge, 1 inch needle for injection D. Massage the site for 2 minutes after the injection
B. Inject the medication into the dorsal gluteal site
When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes uring flow into the tubing. What action is taken next? A. Document the color and clarity of the urine B. Insert the catheter an additional inch C. Ask the client to breathe deeply and slowly exhale D. Inflate the balloon with 5mL of sterile water
B. Insert the catheter an additional inch
The nurse is caring for a middle-aged client who had a Myocardial infarction (MI) 3 days ago. Which finding is most important for the nurse to report? A. Frothy red-tinged sputum B. Irregular heart rate C. Two pound weight gain D. Dependent edema
B. Irregular heart rate
The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase in granulation tissue will develop within 2 weeks," which intervention should the nurse implement? A. Remove heel protector every two hours B. Irrigate wound with sterile normal saline C. Replace dry sterile dressings as needed D. Apply heat for 15 minutes three times daily
B. Irrigate wound with sterile normal saline
An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first time. What is the best intervention for the nurse to implement? A. Clamp the catheter and assist the client with a tub bath B. Keep the catheter intact and assist the client with a shower C. Encourage the client to do self-care and provide personal care products D. Assist the client with a sponge bath in a chair or the bed
B. Keep the catheter intact and assist the client with a shower
A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? A. Across the eye from the bridge of the nose to the right temple B. Longitudinally from the right forehead to the right cheek C. From the mid-forehead over to the right zygomatic process D. From the right lateral forehead surface to the medial nasal crease
B. Longitudinally from the right forehead to the right cheek
A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant? A. Appetite B. Mood C. Withdrawl D. Energy level
B. Mood
Which term describes 2 or more tissues that compose a structure and perform a specific function? A. Elastic tissue B. Organ C. System D. Serous membrane
B. Organ
What technique should the nurse use to administer a medicated ophthalmic ointment? A. Massage the lashes with the excess ointment that is squeezed out when shutting the lids B. Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus C. Pull both upper and lower lids apart to drop the ointment onto the anterior surface of the eye D. Wear gloves when placing the tip of the ointment tube in the center of the lower lid
B. Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus
After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? A. Identify the need for additional supplies to provide an extra dressing change B. Provide perianal care and collect clean linens for the dressing change C. Document the diarrhea that necessitates an additional dressing change D. Position the client for access to the decubiti sties and remove dressings
B. Provide perianal care and collect clean linens for the dressing change
Wrist restrains were applied to a client who was severely agitated and disoriented. In monitoring the client, who is now asleep, which finding should be reported to the charge nurse? A. Respiratory rate decreases from 22 to 16 per minute B. Radial pulse volume decreases from +3 to +1 C. Blood pressure decreases from 130/84 to 120/76 D. Apical pulse rate decreases from 94-84 per minute
B. Radial pulse volume decreases from +3 to +1
In assisting a client to obtain a putum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? A. Advise the client that suctionin will be used to obtain another specimen B. Re-instruct the client in coughing techniques to obtain another specimen C. Provide the client a glass of water and mouthwash to rinse the mouth D. Label the container and place the container in a biohazard transport bag
B. Re-instruct the client in coughing techniques to obtain another specimen
The nurse is providing instructions to the unlicensed assistive personnel (UAP) preparing to instruction is most important for the nurse to emphasize? A. Keep the head of the bed raised while the tube feeding is infusing B. Report any drainage observed around the GT insertion site C. Raise the entire bed while bathing the client to reduce back strain D. Use plenty of pillows to position the client on the side after bathing
B. Report any drainage observed around the GT insertion site
During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse? A. Count the right radial pulse rate B. Reposition the oximeter clip C. Document a pulse deficit D. Count the apical pulse rate
B. Reposition the oximeter clip
The cervix is the opening into the uterine cavity. What is its function in reproduction? A. Accepts and interprets signals of sexual stimuli B. Secretes mucus to facilitate sperm transport C. Serves as the site for union of ovum ans sperm D. Receives the penis during intercourse
B. Secretes mucus to facilitate sperm transport
The nurse is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next? A. Initiate the urine stream B. Seperate the labia C. Position the collection cup D. Observe the urine
B. Seperate the labia
While making the bed of a female client who is sitting in the bedside chair, the nurse observes the client seem anxious. To encourage verbalization by the client, what action should the nurse take? A. Continue to make the bed while conversing with the client B. Sit next to the client at a slight angle to continue the conversation C. Remain standing close enough to the client to hold her hand D. Bring a chair face-to-face with the client for further discussion
B. Sit next to the client at a slight angle to continue the conversation
The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? what information should the nurse provide this client? A. The client should bottle feed and pump her breast for 3 days following immunization B. The vaccine is given to produce maternal antibodies before lactation occurs C. The infant will receive immunization through the mother's breast milk D. The client should not get pregnant for 3 months after immunization
B. The vaccine is given to produce maternal antibodies before lactation occurs
Which food should the practical nurse recommend for a client to increase the dietary intake of potassium?
Baked potatoes
Race
Based on specific characteristics (e.g. skin color, hair color, facial features)
sleep apnea treatment
Behavioral Therapy -weight reduction -avoidance of alcohol, tobacco, sleeping pills -positional therapy Physical or Mechanical Therapy -dental appliance -positive airway pressure device
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.
Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct Answer: B
What color does amitriptyline turn your urine?
Blue/green
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.
Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement. Correct Answer: C
Sitting down with crutches
Both crutches should be in one hand
Once digested, 100% of carbohydrates are converted to glucose. However, approximately 40% of protein foods are also converted to glucose, but this has minimal effect on blood glucose levels
Once digested, what percentage of carbohydrates is converted to glucose
An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? A. Use an over the counter stool softener when needed B. Eat a high protein diet C Increase the fluid intake in your diet D. Decrease the fat content in your diet
C Increase the fluid intake in your diet
A nurse counsels adolescents in a drug rehabilitation program. A nurse performs range-of-motion exercises for a patient on bedrest. A nurse shows a diabetic patient how to inject insulin.
One of the four broad aims of nursing practice is to restore health. Which examples of nursing interventions reflect this goal? Select all that apply.
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.
C) Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.
Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B
While taking an adult's vital signs, the PN notes an irregular radial pulse. What action should the PN implement to obtain the most accurate assessment?
Perform an apical-radial pulse assessment with another nurse
The PN is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the clients comfort?
Perform oral hygiene frequently.
Factors that influence the quality and quantity of sleep
Physical Illness Drugs/Medications Lifestyle Emotional Stress Environment Nutrition Sensory Deprivation
The PN observes a client who begins to choke during a meal. After determining that the client cannot speak, what action should the PN implement?
Place a fist halfway between the xiphoid process and umbilicus.
How should your crutches be positioned when sitting or rising from a chair?
Place on the unaffected side
Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery
Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.
Interventions for a stage 4 pressure ulcer
Prescribed dressing. Surgical intervention. Proteolytic enzymes. Perform nonadherent dressing changes every 12 hr. Treatment may include skin grafts or specialized therapy such as hyperbaric oxygen
What is the purpose of the code of ethics for nurses?
Provide a powerful statement of the ethical values, obligations, and duties of every individual who enters the nursing profession. The code of ethics serves as the nonnegotiable ethical standard of practice.
Patient Centered Care according to QSEN
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.
One can practice reflective practice in many different ways . . .
Reflection *IN* action (present) Reflection *ON* action (past) Reflection *FOR* action (future)
Systemic vascular resistance
Reflects the amount of restriction or dilation of the arteries
What nutritional information should the PN provide a client with heart failure?
Restrict dietary sodium intake
A client is receiving a continuous tube feeding. While checking the gastric residual volume, the PN aspirated 150 mL of gastric contents. What action should the PN take?
Return all aspirated fluid to the stomach followed with water and consult agency policy.
rights of administration
Right: -medication -patient -dosage -route -time -reason -data -response -documentation -to education -to refuse
How do you take a temporal temperature?
Scan the probe across the forehead, over the temporal artery, and then touch the skin behind the earlobe
Which action should the PN implement when administering a subcutaneous injection to a client who weighs 325 pounds?
Select a needle with a longer shaft
ointment
Semisolid preparation containing a drug to be applied externally; also called an unction
During a change-of-shift report, what is the appropriate method to communicate continuity of care?
Situation, Background, Assessment, Recommendation (SBAR)
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.
Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium. Correct Answer: C
lozenge
Small oval, round, or oblong preparation containing a drug in a flavored or sweetened base, which dissolves in the mouth and releases the medication; also called troche
tablet
Small, solid dose of medication, compressed or molded; may be any color, size, or shape; enteric-coated tablets are coated with a substance that is insoluble in gastric acids to reduce gastric irritation by the drug
What are the names of the visual acuity tests?
Snellen and Rosenbaum eye charts.
What is advocacy?
Speaking on behalf of those who cannot speak for themselves.
What type of enteric formula would you give primarily for Patients with hepatic failure, respiratory disease, or HIV
Specialty enteric formula
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.
Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed. Correct Answer: D
What position should the PN place a client in who is receiving an enteral tube feeding?
Supine with the HOB elevated to 30-45 degrees.
What position should the PN place client in who is receiving an enteral tube feeding?
Supine with the head of bed elevated to 30-45 degrees.
Vagus stimulate, adenisone, cardiovert Narrow QRS
Svt
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.
TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B
Purpose of the National Patient Safety Goals (NPSG) (TJC website)
The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
Purpose of the National Patient Safety Goals (TJC website)
The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
Older and more acutely ill patients
The National Advisory Council on Nurse Education and Practice identifies critical challenges to nursing practice in the 21st century. What is a current health care trend contributing to these challenges?
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25
The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.
The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Correct Answer: B
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.
The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C). Correct Answer: D
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. Correct Answer: B
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.
The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high. Correct Answer: A
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.
The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding. Correct Answer: A
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.
The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy. Correct Answer: B
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.
The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct Answer: A
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.
The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). Correct Answer: C
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.
The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of sensory and motor functions. Correct Answer: C
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D). Correct Answer: C
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.
The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D). Correct Answer: B
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C
The PN is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in the client?
The lips and mucous membranes of a client with dark skin are dusky in color
peak level
The maximum concentration of a drug in the body after administration, usually measured in a blood sample for therapeutic drug monitoring.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.
The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.
The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct Answer: B
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A). Correct Answer: A
What is provision 4 of the code of ethics?
The nurse has authority, accountability, and responsibility for nursing practice' makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.
The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented. Correct Answer: D
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.
The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). Correct Answer: A
What is provision 6 of the code of ethics?
The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
What are some of the ANA standards of nursing practice?
The nursing process Ethics Education EBP/Research Quality of Practice Communication Leadership Collaboration Professional Practice Eval Resource Utilization Environmental Health Collegiality
Respiratory therapy
The patient in Room 402 needs a breathing treatment. Who you gonna call...
Radiology
The patient in Room 402 needs a chest xray. Who you gonna call...
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.
The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. Correct Answer: A
A client is receiving a daily script for Lasik 40 mg PO but is unable to swallow. The PN should consult with the healthcare provider about which component of the prescription?
The route of adminstration
Gerontology
The scientific and behavioral study of all aspects of aging and its consequences
Who defines the legal scope of practice for nursing?
The state board of a specific state.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.
Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D). Correct Answer: B
What is theory x?
Theory X assumes the average person dislikes work and will avoid it if possible. Therefore, people must be forced, controlled, and threatened with punishment to accomplish organizational goals.
What must be present in order for medications to pass through the blood brain barrier and placenta?
They must be lipid soluble or have a transport system
Disenfranchised Grief
This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide.
Perceived Loss
This is any loss defined by the client that is not obvious or verifiable to others.
Maturational or Developmental Loss
This is any loss normally expected due to the developmental processing of life. These losses are associated with normal life transitions and help to develop coping skills.
Actual Loss
This is any loss of a valued person, item, or status, such as loss of a job.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.
To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D
The PN contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints?
To ensure the clients safety when the benefits outweighs the risks.
What's an ethical dilemma? Professor Donadio's example of the PT on the vent.
Two (or more) clear moral principles apply, but support mutually inconsistent courses of actions.
TX: insulin, meal spacing
Type I
The practical nurse is irrigation a clients indwelling catheter. After injecting sterile solution as prescribed what action should the PN implement?
Unclamped the tubing and lower the collection bag.
transdermal patch
Unit dose of medication applied directly to skin for diffusion through skin and absorption into the bloodstream
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.
Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat. Correct Answer: D
Class of oxybutynine
Urinary antispasmodic
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.
Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Correct Answer: D
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.
Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B
A client with gastroenteritis, nausea and vomiting is currently on NPO status. The healthcare provider prescribed oral intake to be advanced as towered. Which fluid should the PN offer first?
Water
What would a Weber test show with a pt with conductive hearing loss?
Weber test that lateralizes to the affected ear
What would a Weber test show for a pt with sensorineural hearing loss?
Weber test that lateralizes to unaffected ear
"Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code."
When an older nurse complains to a younger nurse that nurses just aren't ethical anymore, which reply reflects the best understanding of moral development?
Immediate bystander CPR Explanation: The treatment of choice for v-fib is immediate bystander cardiopulmonary resuscitation (CPR), defibrillation as soon as possible, and activation of emergency services
Which of the following is the treatment of choice for ventricular fibrillation
What's a crime?
Wrong against person/property & the public
Can an RN's license be suspended/revoked?
Yes! If said RN becomes carless, reckless, and negligent of ones career and patients.
Immediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present.
You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?
visceral pain
a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera
Causes of hypovolemia
abnormal gastrointestinal losses- vomiting, nasogastric suctioning, diarrhea. abnormal skin losses- diaphoresis. abnormal renal losses- diuretic therapy, diabetes insipidus, renal disease, adrenal insufficiency, osmotic diuretics. third spacing- peritonitis, intestinal obstruction, ascitis, burns. hemorrhage. altered intake- NPO.
Visible ____ muscle movement when breathing is demonstrating labored breathing.
accessory
What can you see with the ophthalmoscope?
allows visualization of the back part of the eyeball (fundus), including the retina, optic disc, macula, and blood vessels.
factors affecting mobility include
alterations in muscles, injury to the musculoskeletal system, abnormal posture, impaired central nervous system, health status in age
metabolic
altered endocrine system, decreased basal metabolic rate, changes in basal metabolic rate, changes in protein, carbohydrate and fat metabolism, decreased appetite with altered nutritional intake, negative nitrogen balance, decreased protein resulting in loss of muscle, loss of weight, alterations in calcium, fluid, and electrolytes, resorption of calcium from bones, decreased urinary elimination of calcium resulting in hypercalemia
short-term goal
an objective behavior or response that you expect a client to achieve in a short time, usually less than a week
long-term goal
an objective behavior or response that you expect a client to achieve over a longer period; usually over several days, weeks, or months
toddler physical development
anterior fontanel closes by 18 months of age. at 24 months should be 4x birth weight. grown 3 in per year. and fine and gross motor skills
atrophine
anticholinergic medications-given to dry the oral and respiratory mucus membranes
Bleeding at the IV site can occur as the result of _____.
anticoagulation
used to treat symptomatic bradycardia
atropine
The nurse should warm the irrigation solution to ______ when irrigating a wound.
body temperature
A blowing sound produced from blood flowing through a narrow/occluded artery is called a ____.
bruit
Functions of red blood cells (erythrocytes)
carry oxygen from the lungs to body tissues and transfer carbon dioxide from the tissues to the lungs. Oxygen transfer is accomplished via the hemoglobin contained in RBC's. Hemoglobin combines readily with oxygen and carbon dioxide.
neurological/ psychosocial changes
changes in emotional status-depression, alteration in self-concept and anxiety. behavioral changes- withdraw, altered sleep/ wake pattern, hostility, inappropriate laughter, and passivity altered sensory perception, ineffective coping
Idiopathic Pain
chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
The nurse should wear ____ gloves to remove an old dressing.
clean
guidelines for writing goals
client-centered singular goal or outcome observable measurable time-limited mutual factors realistic
nursing diagnosis
clinical judgment about individual, family, or community responses to actual & potential health problems or life processes; statement describing the client's actual or potential response to a health problem that nurse is licensed and competent to treat.
What can a patient drink when on a clear liquid diet?
coffee, tea, sports drinks, clear carbonated beverages.
separation
cognitive development. infants learn to separate themselves from other objects in the environment
Implementation skill of nursing process
cognitive skills: application of critical thinking to nursing process interpersonal skills: effective for nursing action-developing a relationship psychomotor skills: integration of cognitive and interpersonal skills
language development
cognitive. responds to noises, vocalizes "oooo" adn "aahhh", laughs and squeals, turns head to rattle sound, pronounces single-syllable words, begins speaking two and three word phases
object permanence
cognivitve. occurs at about 9 months of age. the process by which an infant know that the object still exists when it is hidden from view.
Loss of electricity prevents the oxygen concentrator from functioning, therefore it is good to instruct the pt to ________.
consider the use of a backup power source or generator
What kind of material is safe for use with a home oxygen concentrator?
cotton; not synthetic
causes of hyponatremia
decicient ECF volume, abnormal GI losses- vomiting, nasogastric suctioning, diarrhea, tap water enamas. renal losses- diuretics, kidney disease, adrenal insufficiency, excessive sweating. skin losses- burns, wound drainage, gastrointestinal obstruction, peripheral edema, ascitis
musculoskeletal changes
decreased muscle endurance, strength, and mass, impaired balance, atrophy of muscles, decreased stability, altered calcium metabolism, osteoporosis, contractures, foot drop, altered joint mobility
respiratory changes
decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange, stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypostatic pneumonia, decreased cough response
urine specific gravity and osmolarity
dehydration- increased concentration
serum osmolarity
dehydration-increased hemoconcentration osmolarity (>300 mOsm/L-increased protein, BUN, electrolytes, glucose. overyhydration- decreased hemodilution (osmolarity less than 270 mOsm/L) levels: 180-300 mOsm/L.
1 month
demonstrates head lag. has a present grasp reflex
What would a Rinne test look like for a pt with conductive hearing loss?
demonstrates that air conduction of sound is less than or equal to bone conduction (AC < or = to BC)
actual nursing diagnosis
describes human responses to health conditions or life processes that exist in an individual, family, or community--acute pain
risk diagnosis
describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community
atelectasis
develops when mucus obstructs the bronchioles and the alveoli collapsed directly related to hypoventilation, recumbency, and ineffective coughing. deep breathing helps prevent alveolar collapse
1+ pulse means
diminished, weaker than expected
body-image changes
discovers that his mouth is a pleasure producer, hands and feet are seen as objects of play, discovers smiling causes others to react
sleep apnea
disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep; 3 types: central, obstructive, and mixed apnea
Blood flowing through _______ veins does not produce a sound.
distended jugular
narcolepsy
dysfunction of mechanisms that regulate the sleep and wake states (may fall asleep uncontrollably at times)
Storing food in the mouth is a behavioral sign of what?
dysphagia
nursing care plan
enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care
What is the most important treatment for aggression/anger?
ensure safety
What is dereliction?
evidence that nurses actions did not meet standard of care
Diaphragamatic breathing is an ______ assessment finding.
expected
The most important factor the nurse should consider is the ________ for the AP because it provides information about what tasks are within the scope of practice for the AP.
facility's job description
chronic renal disease
feed PT apple sauce- low potassium content
When ambulating with the walker, a pt should keep his elbows _____.
flexed (20-30 degrees)
Portal of Exit
for microorganisms to grow and multiply they must exit their host, portals of exits include blood, skin, and mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
elimination changes
genitourinary: urinary stasis, change in calcium metabolism with hypercalcemia resulting in renal calculi, decreased fluid intake, poor perineal care, and indwelling urinary catheters resulting in urinary tract infections gastroinestinal: decreased peristalis decreased fluid intake, constipation, then fecal impation, then diarrhea
Risks for the Adolescent
greater independence and separate emotionally from family; tension associated with physical and psychological changes and peer pressures can lead to risk-taking behaviors like smoking or drugs; motor vehicle accidents
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.
gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B
The nurse should consider the amount of supervision the AP requires to determine ___________.
how much time she will need to spend with the AP
What would be the safest method to move a patient with left sided paralysis from the bed to the wheelchair?
hydraulic lift
HCT
hypovalemia- increased hct. dehydration- increased hemoconcentration but not present when dehydration is caused by hemorrhage. overyhydration- decreased hct= hemodilution
The suction catheter should be a certain size when suctioning a treacheostomy to prevent _____ and __________.
hypoxemia; trauma to the mucosa
What should the nurse tell the pt/caregiver to monitor for with a home oxygen concentrator?
hypoxia
When should the nurse assess for bladder distention in a pt with difficulty voiding after the removal of a catheter?
immediately
Bereavement
includes both grief and mourning (the outward display of loss) as the individual deals with the death of a significant individual in his life.
High red blood cell count (polycethemia)
increases in the RBC count occur at high altitudes because less atmospheric weight pushes air into the lungs, causing a decrease in the partial pressure of oxygen and hypoxia. With strenuous physical training, increased muscle mass demands more oxygen.
During post operative care, one of the main concerns is to promote ____ of the patient to give them a sense of control.
independence
developmental changes
infants, toddlers and preschoolers: slower progression in gross motor skills and intellectual and musculoskeletal development, body aligned with line of gravity, resulting in unbalanced posture adolescents: imbalanced growth spurt possibly altered with immobility, delayed development of independence, social isolation adults: alterations in every physiological system, alterations in family and social systems, alterations in job identity older adults: alterations in balance resulting in a major risk for falls & injuries, steady loss of bone mass resulting in weakened bones, decreased coordination, slower walk with smaller steps, alterations in functional status, increased dependence on staff and family
central sleep apnea
involves dysfunction in the brain's respiratory control center, the impulse to breathe temporarily fails, and nasal airflow and chest wall movement cease
What is democratic leadership?
it means that managers and workers work together to make a decision
2.5 years
jumps with both feet. stands on one foot momentarily. draws circles. has good hand-finger coordination
What is the first principle of assigning tasks?
know the nurse practice act for the state in which you are licensed
evaluation
last step of nursing process; used to determine if after application of the nursing process, the client's condition or well-being improved (used to determine if you met expected outcomes, not if nursing interventions were completed)
What are constitutional laws?
laws based on the constitution
What are statutory laws?
laws created by legislative bodies such as congress and state legislatures
What are case laws?
laws determined by the outcome of court cases
hypermobility
leads to diarrhea and is an indication of intolerance to the enternal feeding. the nurse should slow the rate of the feeding to promote PT tolerance
Hyperkalemia
level greater than 5.0 mEq/L. the result of an increased intake of potassium, movement of potassium out of the cells, or inadequate renal excretion
magnesium imbalances
level: 1.3-2.1 mEq/L. found in the bones. found in smaller amounts within the body cells. very small amount in ECF
hypernatremia
level: greater than 145 mEq/L. a serious electrolyte imbalance. can cause significant neurological, endocrine and cardiac disturbances. increased sodium causes hypertonicity fo the serum. this causes a shift of water out of the cells, making the cells dehydration
hyponatremia
level: less than 136 mEq/L. a net gain of water or loss of sodium rich fluids, delays and slows the depolarization of membranes, water moves from the ECF into ICF, which causes cells to swell (cerebral edema). serious complications can result from untreated acute hyponatremia (coma, seizures, respiratory arrest)
hypocalcemia
level: less than 9mg/dL. risk factors: malabsorption syndrome, such as chrohn's disease; end stage renal disease, post thyroidectomy, hypoparathyroidism, repeated transfusion. will have: muscle twitches/ tetany
potassium imbalances
levels: 3.5-5 mEq/L. major cation in ICF. plays a vital role in cell metabolism; transmission or nerve impulses; functioning of cardiac, lung, and muscle tissues; and acid-base balance. has reciprocal action with sodium
calcium imbalances
levels: 9-10.5 mg/dL or 4.5 mg/dL for ionized calcium. found in the bones and teeth. essential for proper functioning of the cardiovascular, neuromuscular, and endocrine systems, as well as blood clotting and bone and teeth formation
physical assessment of oral cavities
look for: -dental caries -periodontal disease -other oral problems (thrush, plaque buildup) -identify actual or potential problems -identify appropriate nursing measures -carry out plan
hypovalemic shock
loss of circulatory volume due to hemorrhage -tachycardia, hypotension, narrow pulse pressure, cold and clammy skin
Patient's with conductive hearing loss hear better in what kind of environments?
loud
When transferring a pt from the bed to the stretcher what should the nurse do with the head of the bed?
lower it as flat as possible
expected outcomes
measurable criteria to evaluate goal achievement
Infectious agent
microorganisms include bacteria, viruses, fungi, and protozoa; can cause disease when there is sufficient number, adequate virulence, ability to enter and survive the host, and susceptibility of the host
Arterial blood gas analysis
most effective way to evaluate acid-base balance and oxygenation, deviation from normal value will indicate that the client is experiencing an acid-base imbalance; measure of: pH, PaCO2, PaO2, oxygen saturation, and HCO3-
Chronic/Persistent Pain
not protective and serves no purpose, lasts longer than anticipated, does not always have an identifiable cause, and leads to great personal suffering, can be cancerous or noncancerous)
Why should a pt not use a walker to pull himself up to stand?
not stable, can lead to injury
Applying sutures is _____ (within/not within) the scope of practice for an RN.
not within
clinical criteria
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
obstructive sleep apnea
occurs when muscles or structures of the oral cavity or throat relax during sleep; the upper airway becomes partially or completely blocked, diminishing (hypopnea) nasal airflow or stopping for as long as 30 seconds
whisper test (CNVIII)
one ear is occluded and the other ear is tested to see if the client can hear whispered sounds without seeing your mouth move. reapeat with the ear -the client can hear you whisper softly 30 to 60 cm away.
cardiovascular changes
orthostatic hypotension, less fluid volume in the circulatory system, stasis of blood in the legs, diminished autonomic response, decreased cardiac output leading to poor cardiac effectiveness, which results in increased cardiac workload, increased oxygenation requirement, increased risk of thrombus development
electrolytes, BUN, and creatinine
overhydration/hypervolemia- decreased electrolytes, BUN, and creatinine
nursing action for hyperventilation
oxygen therapy, diaphragmatic breathing to relax patient, incentive spirometer
referred pain
pain that originates in one part of the body and is perceived in an area distant to that part.
What skin observation indicates that a pt has decreased oxygen to the tissues?
pallor
PaO2
partial pressure of oxygen in arterial blood; normal range is 80-100mm Hg; less than 60mm Hg leads to anaerobic metabolism, resulting in acidic production and metabolic acidosis; hyperventilation also causes a decrease in PaO2, or respiratory alkalosis
Nursing is also,
patent-centered, meaning the patient drives the entire process.
What are some examples of ethical dilemmas?
peer reporting, end-of-life care, genetic testing, resource allocation, professional boundaries
___________ refers to how medications run through the body
pharmacokinetics
dependent nursing intervention
physician initiated, actions that require an order from a physician or another health care professional
factors that influence pain
physiological factor: age, fatigue, genes, neurological function; social factors: attention, previous experience, family and social support; Spiritual factors; psychological factors: anxiety, coping style; Cultural Factors: meaning of pain, ethnicity
Reservoir
place where a pathogen can survive but may not multiply, may be in food, oxygen, and water; factors that affect bacteria growth are temperature, pH, and light (organisms can thrive in the dark)
What are the 4 steps of Fayol's functions of management?
planning, organizing, directing, and controlling
nursing action for aspiration
positioning to avoid aspiration, coughing to clear sputum/fluid, maintain a clear airway
Functions of platelets (thrombocytes)
prevent bleeding
nursing process
professional nurse's approach to identify, diagnose, and treat human responses to health and illness; 5 steps: assessment, diagnosis, planning, implementation, and evaluation
toddler self-concept development
progressively see themselves a separate from parents and increase their explorations away from them
milk
promotes sleep
nursing actions that control or eliminate infections in the clinical setting
properly administering antibiotics, monitoring response to drug therapy, and using proper hand hygiene and standard precautions; supportive therapy would include proper nutrition and rest
inflammatory response
protective reaction that serves to neutralize pathogens and repair body cells
Acute/Transient Pain
protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response
How do you measure perfusion?
pulse ox
age-appropriate activities
rattles, mobiles, teething toys, nesting toys, playing pat-a-cake, playing with balls, reading books
Physiological Factors affecting oxygenation
reduced oxygen carrying capacity, reduced inspired oxygen concentration, hypovolemia, higher metabolic rate, impaired chest wall movement-pregnancy, obesity, musculoskeletal abnormalities, trauma, neuromuscular diseases, central nervous system alterations, influences of chronic disease
arterial blood gases
respiratory alkalosis- decreased PaCO2 (less than 35 mm Hg), increased pH (greater than 7.45)
sleep deprivation
result of dyssomnia, causes may be illness, emotional stress, medications, environmental substances, and variability in the timing of sleep due to shift work
What type of healing intention is a stage 3 pressure ulcer, and a burn?
secondary intention
Art of nursing
skilled application of the knowledge base to help others reach maximum health and quality of life
viscosity of the solution
some medications are more viscous than others and require a large lumen needle to inject the drug
Weber's test identifies _____.
sound lateralization
When speaking to a pt with hearing loss, why would speaking loudly not be the best action?
speaking loudly distorts sound and increases difficulty in hearing
The nurse should initiate a referral to what kind of therapy when a pt has difficulty swallowing after a stroke?
speech
Asynchronous closure of the aortic and pulmonic valves is known as ______ of S2.
splitting
The nursing process is:
systemic, dynamic, interpersonal, outcome oriented, and universally applicable.
pathogenicity
the ability of a pathogen to produce an infectious disease in an organism
What is accountability?
the ability to answer for one's actions
etiology
the cause of a disease, and is alway within the domain of nursing practice and a condition that responds to nursing interventions
medical diagnosis
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures
What is the second principle of assigning tasks?
the nurse cannot assign tasks that involve assessment, planning, evaluation, or accountability
priority setting
the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
What is the third principle of assigning tasks?
the person to whom the assignment was given may not assign the task to another person
Oxygen Saturation
the point at which hemoglobin is saturated by O2, normal range is 95%-99%
trough level
the point when the drug is at its lowest concentrations, indicating the rate of elimination
The ICN also says that nursing care includes:
the promotion of health, prevention of illness, & the care of ill, disabled, & dying.
scientific rationale
the reason that you chose a specific nursing action, based on supporting evidence
Modes of Transmission
the specific way a disease is transmitted, most common: (unwashed hands) direct (person-person), physical contact, indirect (susceptible host to inanimate object), droplet (large particles that travel up to 3 ft), airborne, vehicles, vector (mosquitos)
What happens during ventricular systole?
the ventricles force blood into the aorta, it represents the maximum amount of pressure exerted on the arteries
The older adult and oxygenation
trachea & large bronchi become enlarged from calcification of the airways; alveoli enlarge, reducing the surface area available for gas exchange; the number of cilia is reduced, causing a decrease in the effectiveness of the cough mechanism-which can cause respiratory infection
2 years
walks up and down stairs. builds a tower with six or severn blocks
To decrease the risk of spreading Shigella, the nurse should _____.
wash hands before and after client contact
Causes of overhydration
water replacement without electrolyte replacement (strenuous exercise with profuse diaphoresis)
How should you take phenazopyridine?
with food
Initiating an enteral feeding is _____ (within/not within) the scope of practice for an RN.
within
