Skills 1-4

Other safety concerns for homes and communities include:

Electrical shock: Abuse: Bioterrorism: Suffocation:

Hyperkalemia

High potassium

The nurse has washed a patient's arms. Which area should the nurse wash next? A. Hands B. Chest C. Abdomen D. Legs

A. Hands *The hands should be washed next. The chest should be washed after the hands. The abdomen should be washed after the chest. The legs should be washed after the abdomen.

What would the nurse instruct nursing assistive personnel (NAP) to report while feeding any patient on aspiration precautions? A. Amount of food ingested B. Coughing C. Poor appetite D. Food preferences

B. Coughing

Which action would the nurse take if an intravenous (IV) insertion site appeared red, warm, and swollen? A. Assess for blood return. B. Discontinue the infusion. C. Change the existing dressing. D. Secure the tubing with more tape.

B. Discontinue the infusion.

Complete bed bath:

Bath administered to totally dependent patient in bed

Client's Self-Measurement of BP: Advantages vs. Disadvantages

Benefits - Detection of new problems (prehypertension) - Patients with hypertension can provide to their health care provider info about patterns of BP - Self-monitoring helps adherence to therapy Disadvantages - Improper use risks inaccurate readings - Unnecessary alarming of client - Clients may inappropriately adjust medications

Biot's respiration

Biot's respiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.

Urgency

An immediate and strong desire to void that is not easily deferred

Epidermis

The outer layer, composed of several layers of cell undergoing different maturational stages & shields underlying tissues from H2O loss & injury

Evaluation

Through the patient's eyes - Include the patient and caregiver in the evaluation process Patient outcomes - Individualize nursing interventions - Patients with impaired skin integrity - Ongoing evaluations - Validated risk-assessment tool

What should be done if a medication error is made?

- Monitor client - Notify: MD/NP/ PA/ Primary Provider; Team Leader/Charge Nurse; - While in school, notify your instructor - Give antidote, if ordered - Quality Assurance Report

Organs of Concern for Hygiene Care: The Hands

- An impairment or injury in any of the hands interfere with an individual's ability for self-help. - Hand care

Red or Blue ends for thermometers represent:

- Blue is for ORAL temperatures - Red is for RECTAL temperatures

Performing Urinary Catheterization: Secure the catheter to the ______ ______ or ________ ________ of a male client

upper thigh; lower abdomen

Metabolic Changes caused by immobility:

- Decreased metabolic rate - Negative nitrogen balance - Anorexia - Negative calcium balance

Implementation and Evaluation: PASS

1. Pull the pin, breaking the seal 2. Aim nozzle 3. Squeeze handle 4. Sweep at the base of the fire

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus

3. Pressure ulcers

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 1. Fluid status 2. Potassium 3. Lipids 4. Nitrogen balance

4. Nitrogen balance

Documentation of temperature:

- Record in client's record - Electronic record, nurse's notes, vital sign flow sheet - "R" for rectal - "AX" for axillary

Implementation: Drainage Evacuation

Constant, low-pressure vacuum to remove and collect drainage

Mild allergic

Flushing, itching, urticaria (hives) Cause: - Antibodies against donor plasma proteins

Infection Control Principles: Chain of infection

Infection can be prevented if the chain is interrupted

Dribbling

Leakage of small amounts of urine despite voluntary control of micturition

Subclavian Central Line

More short term

Performing Urinary Catheterization: To expose the urinary meatus

Separate the labia minora and retract the tissue upward

Extension

Straightening a limb at a joint

Suffocation

When air no longer reaches the lungs and respiration ceases

Defenses Against Infection

- Normal flora - Inflammation - Body system defenses

Introduction of whole blood or blood components into venous circulation

- Whole blood - Packed Red Blood Cells - Platelets - Fresh Frozen Plasma - Albumin

Foot Odors:

Foot odors are result of excess perspiration, promoting microorganism growth.

Insomnia

Insomnia, the most common sleep disorder, is a symptom patients experience when they chronically have difficulty falling asleep.

Pressure ulcers:

Pressure sore, decubitus ulcer, or bed sore Pathogenesis - Pressure intensity: tissue ischemia; blanching - Pressure duration - Tissue tolerance

Adduction

The movement of a body part toward the body's midline

Hypocalcemia

Too little calcium

Hypomagnesemia

Too little serum magnesium

Hyponatremia

Too little sodium

Hypercalcemia

Too much calcium

Establishing Safe Environments: Adaptations for Visual Loss.

With reduced depth perception a person is unable to judge how far away objects are located. This is a special danger when he or she walks down stairs or over uneven surfaces. Driving is a particular safety hazard for older adults with visual alterations. Reduced peripheral vision prevents a driver from seeing a car in an adjacent lane. A sensitivity to glare creates a problem for driving at night with headlights. Vision is a primary consideration for safety, but there are other factors as well. In the case of older adults, decreased reaction time, reduced hearing, and decreased strength in the legs and arms further compromise driving skills. Some safety tips to share with those who continue to drive include the following: drive in familiar areas, do not drive during rush hour, avoid interstate highways for local drives, drive defensively, use rear-view and side-view mirrors when changing lanes, avoid driving at dusk or night, go slow but not too slow, keep the car in good working condition, and carry a preprogrammed cellular phone. The presence of visual alterations makes it difficult for a person to conduct normal activities of living within the home. Because of reduced depth perception, patients can trip on throw rugs, runners, or the edge of stairs. Teach patients and family members to keep all flooring in good condition, and advise them to use low-pile carpeting. Thresholds between rooms need to be level with the floor. Recommend the removal of clutter to ensure clear pathways for walking and arrangement of furniture so a patient can move about easily without fear of tripping or running into objects. Suggest that stairwells have a securely fastened banister or handrail extending the full length of the stairs. Front and back entrances to the home, work areas, and stairwells need to be lighted properly. Light fixtures need high-wattage bulbs with wider illumination. There needs to be a light switch at the top and bottom of stairwells. It is also important to be sure that lighting on the stairs does not cast shadows. Have a family member paint the edge of steps so the patient can see each step, especially the first and last, clearly. When possible have patients replace steps inside and outside the home with ramps. An added consideration is to administer eye medications safely (see Chapter 32). Patients need to closely adhere to regular medication schedules for conditions such as glaucoma. Labels on medication containers need to be in large print. Make sure that a friend or spouse is familiar with dosage schedules in case a patient is unable to self-administer a medication. Patients with visual impairments often have difficulty manipulating eyedroppers.

Which statement or question best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in administering oral medications? A. "Does the patient need her pain medication?" B. Please make sure the patient has plenty of fresh water to take with her pills." C. "How much did the pain medication improve her pain?" D. "Stay with the patient until he swallows all the pills."

B. Please make sure the patient has plenty of fresh water to take with her pills."

Homeostasis:

Balance of fluids, electrolytes, acid & bases.

Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test? A. A raised wheal the size of a mosquito bite B. A bruised area 10 mm or greater in diameter C. A hard, raised area 15 mm or greater in diameter D. A flat, reddened area 5 mm or greater in diameter

C. A hard, raised area 15 mm or greater in diameter

Economic consequences of pressure ulcers:

Medicare and Medicaid: no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization

Colonization:

Presence and growth of microorganisms within a host without tissue invasion or damage.

Sterilization

The complete elimination or destruction of all microorganisms, including spores

A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response? A. "When did you start experiencing the pain?" B. "Rate the pain on a scale of 1 to 10." C. "I'll assess your perineal area for the possible cause of the pain." D. "Would you like some pain medication before I continue with your care?"

A. "When did you start experiencing the pain?" *A nurse should ask the patient about his concerns and the perineal pain first. This is the best response for the nurse.

Balance

- Complex mechanisms - Proprioception * Awareness of posture, movement, changes in equilibrium * Knowledge of position, weight, resistance of objects in relation to body

Risk factors for pressure ulcer development:

- Impaired sensory perception - Impaired mobility - Alteration in LOC - Shear - Friction - Moisture

Chain of Infection

- Infectious agent or pathogen - Reservoir or source for pathogen growth - Portal of exit - Mode of transmission - Portal of entry - Susceptible host

Normal flora

- Microorganisms - Maintain a sensitive balance with other microorganisms to prevent infection. Any factor that disrupts this balance places a person at increased risk for acquiring a disease.

Vital signs are used to:

- Monitor patient's condition - Identify problems - Evaluate response to intervention

Cardiovascular changes with immobility:

- Orthostatic hypotension - Increased cardiac workload - Thrombus formation - Dependent edema

What is used to describe pulse character:

- Rate - Rhythm - Strength

Health Care-Associated Infections

- Results from delivery of health services in a health care facility - Patients at greater risk for health care-associated infections (HAIs) * Multiple illnesses * Older adults * Poorly nourished * Compromised immune system *Maintaining a sterile field is critical

Nursing Process: Temperature: Diagnosis

- Risk for imbalanced body temperature - Hyperthermia - Hypothermia - Ineffective thermoregulation

Nursing Responsibilities for Diagnostic Examination for Urinary Elimination:

- Signed consent - Assess for allergies - Bowel-cleansing agents - Pretest diets (clear liquids; NPO) - Post-test: I&O, Assess voiding and urine; encourage fluid intake.

Alternative to Catheterization

- Suprapubic Catheter: Inserted surgically into the bladder through the abdominal wall above the symphysis pubis. - External Catheter: External catheter called condom catheter fits over the penis.

Why is it important to know specific guidelines for positioning a patient?

- Although each procedure for positioning has specific guidelines, there are universal steps to follow for patients who require positioning assistance. - Following the guidelines reduces the risk of injury to the musculoskeletal system when a patient is sitting or lying. - When joints are unsupported, their alignment is impaired. - Likewise, if joints are not positioned in a slightly flexed position, their mobility is decreased. - During positioning also assess for pressure points. - When actual or potential pressure areas exist, nursing interventions involve removal of the pressure, thus decreasing the risk for development of pressure ulcers and further trauma to the musculoskeletal system. In these patients use the 30-degree lateral position.

Nursing Care for Clients with Incontinent Urinary Diversion

- Assess intake and output - Note any changes in urine color, odor, or clarity (mucous shreds are commonly seen in the urine of clients with an ileal diversion). - Changing a pouch: * Gently cleanse skin surrounding stoma. * Measure the stoma and cut opening in pouch * Press pouch over stoma * Frequently assess the condition of the stoma and surrounding skin - Consult with the wound ostomy continence nurse (WOCN)

Nursing Process and BP Determination

- Assessment of blood pressure and pulse evaluates the general state of cardiovascular health. - Hypertension, hypotension, orthostatic hypotension and narrow/wide pulse pressures are defining characteristics of certain nursing diagnoses.

Coordinated Movement

- Balanced, smooth, purposeful movement - Result of proper functioning of: * Cerebral cortex = Initiates voluntary movement * Cerebellum = Coordinates motor activity * Basal ganglia = Maintains posture

Alignment and Posture

- Brings body parts into position that promotes optimal balance and body function - Person maintains balance as long as line of gravity passes through center of gravity and base of support

Common Foot and Nail Problems:

- Callus - Corns - Plantar Warts - Athlete's Foot (Tinea Pedis) - Ingrown Nails - Foot Odors *Extra precaution must be observed with DIABETIC patients. Check facility SOP.

Factors influencing pressure ulcer formation and wound healing:

- Nutrition - Tissue perfusion - Infection - Age - Psychosocial impact of wounds

Cognitive Function with exercise:

- Positive effects on decision-making and problem solving processes, planning, and paying attention - Induces cells in the brain to strengthen and build neuronal connections

Nursing diagnoses associated with impaired skin integrity and wounds:

- Risk for infection - Imbalanced nutrition: less than body requirements - Acute or chronic pain - Impaired physical mobility - Impaired skin integrity - Risk for impaired skin integrity - Ineffective peripheral tissue perfusion - Impaired tissue integrity

Nurse's Responsibility in Transfusion Reactions

- STOP the Infusion - KVO with NS (change tubing) - Immediately notify MD or emergency response team - Remain with patient, observe s/sx and monitor VS every 5 minutes. - Prepare to administer emergency drugs and CPR - Return blood container, tubing, labels, etc. to blood bank. - Obtain blood and urine specimens per MD or protocol.

Which statement made by the parent of a school-age child requires follow-up by the nurse? 1. "I encourage evening exercise about an hour before bedtime." 2. "I offer my daughter a glass warm milk before bedtime." 3. "I make sure that the room is dark and quiet at bedtime." 4. "We use quiet activities such as reading a book before bedtime."

1. "I encourage evening exercise about an hour before bedtime."

Two types of Continent Urinary Diversions:

1. Continent Urinary Reservoir: distal ileum and proximal portion of colon creates a pouch with opening (stoma); ureters from bladder connect to pouch (Collects urine using catheter). 2. Orthotopic Neobladder uses an ileal pouch to replace the bladder. Void using Valsalva technique.

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: (Select all that apply.) 1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 2. Stopping acetaminophen when the pain becomes very severe. 3. Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4. Avoiding total sedation, regardless of the severity of the pain. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the "as-needed" order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record

2. Assess the catheter and drainage tubing for obvious occlusion

An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.) 1. Slow, cautious behavioral style 2. Inattention and neglect, especially to the left side 3. Cloudy or opaque areas in part of the lens or the entire lens 4. Visual spatial alterations such as loss of half of a visual field 5. Loss of sensation and motor function on the right side of the body

2. Inattention and neglect, especially to the left side 4. Visual spatial alterations such as loss of half of a visual field

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4° C (99.3° F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%

2. Radial pulse rate: 72 and irregular 4. Respiratory rate: 28 5. Oxygen saturation: 99%

A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route

2. The time interval

Advantages and Disadvantages of Oral Temperature Measurement Sites

Advantages: - Easily accessible—requires no position change - Comfortable for patient - Provides accurate surface temperature reading - Reflects rapid change in core temperature - Reliable route to measure temperature in patients who are intubated Disadvantages: - Causes delay in measurement if patient recently ingested hot/cold fluids or foods, smoked, or is receiving oxygen by mask/cannula - Not for patients who had oral surgery, trauma, history of epilepsy, or shaking chills - Not for infants, small children, or patients who are confused, unconscious, or uncooperative - Risk of body fluid exposure

What would the nurse do first to ease breathing for a patient with mild dyspnea? A. Administer oxygen at 2 L/min by nasal cannula. B. Help the patient into an upright sitting position. C. Monitor the patient's pulse oximetry level. D. Determine if the patient has a history of respiratory pathology.

B. Help the patient into an upright sitting position. The nurse would first try to ease the patient's breathing using a noninvasive intervention such as this one. Placing the patient in a sitting position improves lung expansion.

Flexion

Bending a limb at a joint

The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order? A. Infusing D5W 1000 mL for 8 hours and then discontinuing the infusion B. Infusing D5W at a rate of 125 mL/hr for 24 hours and then discontinuing the infusion C. Infusing D5W at a rate of 125 mL/hr until the health care provider changes the order D. Calling the health care provider to clarify the order

C. Infusing D5W at a rate of 125 mL/hr until the health care provider changes the order

Vital Signs monitor functions of the body and reflect

Changes that may not be observed. For ex. Hypertension known as silent killer.

Poisoning

Intentional or unintentional ingestion, inhalation, injection, or absorption through the skin of any substance harmful to the body

Single Order

Sometimes a health care provider orders a medication to be given once at a specified time. This is common for preoperative medications or medications given before diagnostic examinations.

Hypermagnesemia

Too much serum magnesium

Athlete's Foot (Tinea Pedis)

Athlete's foot is fungal infection of foot; scaling and cracking of skin occurs between toes and on soles of feet. Small blisters containing fluid appear.

Which instruction reflects the nurse's correct understanding of the role of nursing assistive personnel (NAP) in caring for a patient receiving an intravenous (IV) antibiotic medication by piggyback? A. "Assess the IV site frequently for signs of infiltration." B. "Let me know immediately if the patient complains of pain at the IV site." C. "Notify the physician that the patient is allergic to the medication prescribed." D. "Remember to hang the piggyback medication higher than the primary solution."

B. "Let me know immediately if the patient complains of pain at the IV site."

What instruction might the nurse give to nursing assistive personnel (NAP) regarding postoperative exercises? A. "Find out if the patient has any language barriers." B. "Let me know when the patient actually begins exercising." C. "Please review a copy of the preoperative literature with the patient." D. "Assess the method of learning the patient would prefer."

B. "Let me know when the patient actually begins exercising."

Which device is used for wound irrigation? A. 19-gauge needle attached to a 10-mL syringe B. 19-gauge needle attached to a 35-mL syringe C. Sterile container held 30.5 cm (12 inches) above the wound D. Foley irrigating syringe

B. 19-gauge needle attached to a 35-mL syringe

What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback? A. Use a site into which a primary solution is already infusing. B. Assess the IV site before initiating the IV piggyback medication. C. Select a relatively small vein to infuse the IV medication. D. Instruct NAP to notify you immediately if the insertion site appears swollen.

B. Assess the IV site before initiating the IV piggyback medication. *Assessing IV site placement and patency before initiating an IV medication is important in preventing IV infiltration.

Which instruction should be given to a patient to ensure safety when self-applying an antibiotic ointment? A. It is not necessary to allow refrigerated eye medication to warm to room temperature before administration. B. Do not apply pressure directly to the eyeball when removing excess medication. C. When cleaning the eye before administration, gently wash from the outer to the inner canthus. D. Apply a warm, damp washcloth to the eye for several minutes to remove any crusted discharge.

B. Do not apply pressure directly to the eyeball when removing excess medication. * Applying pressure to the eyeball may injure the eye.

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly? A. Use an infusion pump to regulate the flow rate of the piggyback medication. B. Hang the piggyback medication higher than the primary fluid. C. Attach the piggyback medication to the most proximal insertion port on the primary tubing. D. Use a secondary infusion set for the piggyback tubing.

B. Hang the piggyback medication higher than the primary fluid.

Partial bed bath:

Bed bath that consists of bathing only body parts that would cause discomfort if left unbathed such as the hands, face, axillae, and perineal area. Partial bath may also include washing back and providing back rub. Provide a partial bath to dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts.

Which statement by the patient would indicate that he or she understands the safe use of oxygen? A. "The nurse told me that my oxygen saturation must be maintained at 85% or above." B. "I know that oxygen is a medication I can adjust whenever I need to." C. "I'll alert the nurse immediately if I have any increased difficulty breathing." D. "I often experience difficulty breathing for no apparent reason, but that is expected."

C. "I'll alert the nurse immediately if I have any increased difficulty breathing."

Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? A. "Remember to wear gloves to minimize the risk for infection." B. "Be sure to keep pressure on the site for at least 2 to 3 minutes." C. "Let me know if you notice any bleeding on the site dressing." D. "Make sure the patient knows to notify me if the IV site becomes painful."

C. "Let me know if you notice any bleeding on the site dressing."

What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? A. Advising the patient to call for assistance before getting out of bed. B. Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed. C. Observing the six rights of medication administration. D. Monitoring the patient for signs of hypoxia.

C. Observing the six rights of medication administration.

Which action minimizes the risk of introducing glass particles into the syringe when drawing medication from an ampule? A. Using minimal force to snap the neck of the ampule B. Using gauze to cover the top of the ampule when snapping it C. Using a filter needle or straw to draw the medication from the ampule D. Allowing the medication to settle after the ampule has been snapped open

C. Using a filter needle or straw to draw the medication from the ampule

Acute intravascular hemolytic

Chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinuria, hemoglobinemia, sudden oliguria (acute kidney injury), circulatory shock, cardiac arrest, death Cause: - Infusion of ABO- incompatible whole blood, RBCs, or components containing 10 mL or more of RBCs - Antibodies in recipient's plasma attach to antigens on transfused RBCs, causing RBC destruction

Circulatory overload

Dyspnea, cough, crackles, or rales in dependent lobes of lungs; distended neck veins when upright Cause: - Blood administered faster than circulation can accommodate

Define Frostbite

Injury to body tissues caused by exposure to extreme cold, typically affecting the nose, fingers, or toes and sometimes resulting in gangrene.

Implementation and Evaluation: RACE

Is an acronym for the fire emergency response used by many health care facilities. The letters stand for: - R: Rescue all patients in immediate danger, and move them to safe areas. - A: Activate the manual-pull station or fire alarm, and have someone call 911. - C: Contain the fire by closing doors, confining the fire, and preventing the spread of smoke. - E: Extinguish the fire if possible after all patients are removed from the area.

Catheter Gauge Sizes

Lower the number = larger catheter Sizes: - 16 gauge for trauma clients, rapid fluid volume - 18-20 gauge for surgical clients, rapid blood administration - 22-24 gauge for all other clients (children, adults) *Also Depends on vein size, fluid being infused.

Musculoskeletal changes with immobility:

Muscle effects - Patient loses lean body mass. - Muscle weakness/ atrophy Skeletal effects - Disuse osteoporosis - Joint contracture

Generic name

Name used throughout the drug's lifetime

Nursing Process: Nursing Diagnosis

Nursing diagnosis for infection:

What is hemiparesis?

One-sided weakness

Skin Rashes

Skin eruptions that result from overexposure to sun or moisture or from allergic reaction (flat or raised, localized or systemic, pruritic or nonpruritic)

Pharmacokinetics

Study of absorption, distribution, biotransformation, and excretion of drugs

Pharmacology

Study of the effect of drugs on living organisms

Medication

Substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of disease

Nurses develop patient-specific interventions that are continually evaluated to measure

The patient's progress toward goal attainment.

Perform assessment of body alignment with the patient standing, sitting, or lying down. This assessment has the following objectives:

• Determining normal physiological changes in body alignment resulting from growth and development for each patient • Identifying deviations in body alignment caused by incorrect posture • Providing opportunities for patients to observe their posture • Identifying learning needs of patients for maintaining correct body alignment • Identifying trauma, muscle damage, or nerve dysfunction • Obtaining information concerning other factors that contribute to incorrect alignment such as fatigue, malnutrition, and psychological problems

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? A. Assesses the patient for weakness, dizziness, or postural hypotension B. Arranges for at least three healthcare personnel to assist in the transfer C. Makes sure the patient agrees to the intervention D. Applies clean gloves

A. Assesses the patient for weakness, dizziness, or postural hypotension

Ability of Medication to Dissolve

- Ability for medication to dissolve depends on form or preparation. - Blood flow to the site of Administration - Body Surface Area - Lipid solubility

Asepsis

- Absence of pathogenic (disease-producing) microorganisms - Medical asepsis (maintained through sterile technique) - Standard precautions - for EVERY patient - Hand hygiene - Alcohol-based hand rub

Common Skin Problems:

- Acne - Dry Skin - Skin Rashes - Contact Dermatitis - Abrasion

Fluid Balance - Assessment: Nursing History

- Age: very young and old at risk - Environment: excessively hot? - Dietary intake: fluids, salt, foods rich in potassium, calcium, and magnesium - Lifestyle: alcohol intake history - Medications: include over-the-counter (OTC) and herbal, in addition to prescription medications

Pulse Rate:

- Apical rate: S1 and S2, "lub" + "dub" = 1 heartbeat - Lub-dubs per minute = Rate - Tachycardia - fast; over 100 - Bradycardia - slow; under 60 - Pulse deficit = Difference between radial and apical pulse rates

Label IV site with

- Date - Time - Size of catheter - Initials

Nursing Process: Implementation

- Health promotion * Preventing an infection from developing or spreading. Patient teaching. - Acute care * Treating an infectious process includes eliminating the infectious organisms and supporting the patient's defenses - Asepsis (aka clean technique) - Cleaning

Assessment for medication administration

- History - Allergies - Medications - Diet History - Patient's Perceptual or Coordination Problems - Current condition - Patient's attitudes - Adherence to medication therapy - Patient education

Drug allergy

- Immunologic reaction to drug - Mild to severe reactions (anaphylaxis)

Adults:

- Physiological systems are at risk - Changes in family and social structures

Starting an Intravenous Infusion

- The type and amount of solution to be infused - The exact amount (dose) to be added to a compatible solution (usually pharmacist prepares) - The rate of flow or the time over which the infusion is to be completed

Digital Removal of Stool

- Use if enemas fail to remove an impaction. - Last resort in managing severe constipation.

A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements made by the patient indicates that additional teaching is needed? 1. "I am at risk for injury from temperature extremes." 2. "I may be able to dress more easily with zippers or pullover sweaters." 3. "A home care nurse may help me figure out how to be more independent." 4. "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."

4. "I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first."

When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: 1. Congestive heart failure 2. Pneumonia 3. Arthritis 4. Thrombocytopenia

4. Thrombocytopenia

What might the nurse do to improve a patient's cooperation during the removal of an IV access device? A. Describe the entire procedure to the patient. B. Assure the patient that you will remove the IV catheter quickly. C. Assure the patient that the procedure will take only about 5 minutes. D. Tell the patient that the procedure will cause only a slight burning sensation.

A. Describe the entire procedure to the patient.

Make sure ear pieces of stethoscope are facing

Anteriorly

Which statement might a nurse make to nursing assistive personnel (NAP) when caring for a patient prescribed an intravenous (IV) bolus of analgesic medication? A. "Assess the IV site frequently for signs of inflammation." B. "Let me know immediately if the patient complains of pain at the insertion site." C. "Make sure the patient knows what results to expect from the medication." D. "Observe the IV site for sudden swelling when the IV bolus is administered."

B. "Let me know immediately if the patient complains of pain at the insertion site."

How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? A. Asking the patient about symptoms of respiratory difficulty. B. Comparing respiratory assessment data from before and after the suctioning procedure. C. Confirming that the patient's pulse oximetry value is >90%. D. Auscultating the patient's chest after suctioning.

B. Comparing respiratory assessment data from before and after the suctioning procedure.

The nurse is preparing to administer several oral medications when the patient says he would like to take his pills with orange juice. What is the nurse's best response? A. Determine whether the patient's prescribed diet includes orange juice. B. Establish whether the medications may be taken with orange juice. C. Ask the dietary aide to order extra orange juice for the unit. D. Administer the pills with orange juice.

B. Establish whether the medications may be taken with orange juice.

Which measurements would the nurse use to calculate the surface area of a patient's pressure injury? A. Height and weight B. Length and width C. Length and depth D. Width and depth

B. Length and width

What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? A. Arterial blood gas (ABG) levels B. Oxygen flow meter setting C. Respiratory rate D. Temperature

B. Oxygen flow meter setting

Why does the nurse clamp the nasogastric tube before removing it from a patient? A. To suppress the cough reflex B. To keep any fluid from flowing out C. To hinder the gag reflex D. To prevent transmission of microorganisms

B. To keep any fluid from flowing out

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? A. Four B. Two C. One D. None

B. Two

Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment (PPE). C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, timely way.

B. Use appropriate personal protective equipment (PPE).

Vitals include:

BP, temperature, pulse, respiration, pain (fifth vital sign), and O2 stats (sometimes)

Colloids

Blood and blood components

Hypoventilation

Breathing at an abnormally slow rate, resulting in an increased amount of carbon dioxide in the blood.

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient who is prescribed an intradermal injection? A. "Be sure to wear clean gloves during the injection." B. "Tell him it's OK; the site should look like a mosquito bite." C. "Immediately report any patient complaints of itching or dyspnea." D. "Remind the patient to come back in 48 to 72 hours so we can evaluate the site."

C. "Immediately report any patient complaints of itching or dyspnea."

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? A. Coordinate extra help. B. Assess the patient's vital signs. C. Assess the patient's physiological capacity to transfer. D. Determine whether to transfer the patient to a wheelchair or chair.

C. Assess the patient's physiological capacity to transfer. *Assessing the patient's physiological capacity to transfer determines the patient's ability to tolerate and assist with the transfer and whether special adaptive techniques are necessary.

Combined Volume and Osmolality Imbalance:

Clinical Dehydration

Asymptomatic:

Clinical signs and symptoms are not present.

Symptomatic:

Clinical signs and symptoms are present.

What will the nurse need before removing a patient's nasogastric tube? A. Evidence of hypoactive bowel sounds in all quadrants B. Absence of abdominal pain and distention C. Assurance that the patient can pass flatus D. A health care provider's order

D. A health care provider's order

Assessment of Ventilation

Easy to assess: - Respiratory rate: breaths/minute - Ventilatory depth: deep, normal, shallow - Ventilatory rhythm: regular/irregular - Diffusion and perfusion measured by oxygen saturation of the blood - Arterial oxygen saturation *Costal breathing - thoracic breathing **Diaphragmatic breathing can see in abdomen

Full-thickness wound repair:

Hemostasis, inflammatory, proliferative, and maturation

Incontinence

Inability to control passage of feces and gas to the anus

Pharmacy

Prepares, makes, and dispenses drugs as ordered

What are the clinical signs of thrombophlebitis?

Signs and symptoms of superficial thrombosis include palpable veins and surrounding areas that are tender to the touch, reddened, and warm. Temperature elevation and edema may or may not be present. Signs and symptoms of deep vein thrombosis (DVT) include swollen extremity; pain; warm, cyanotic skin; and temperature elevation. Homans' sign (pain in the calf on dorsiflexion of the foot) is no longer considered a reliable indicator

Fluid Balance: Evaluation

Through the patient's eyes - Review with patients how well their major concerns regarding fluid, electrolyte, or acid-base situations were alleviated or addressed. Patient outcomes - Evaluate the effectiveness of interventions using the goals and outcomes established for the patient's nursing diagnoses.

Ingrown Nails

Toenail or fingernail grows inward into soft tissue around nail. Ingrown nail often results from improper nail trimming.

Type of temperature alterations:

- Pyrexia (fever): - Hyperthermia - Heatstroke (104 F or higher) - Heat exhaustion - Hypothermia - Frostbite *Hyperthermia, heatstroke and heat exhaustion caused by environmental factors, not within body itself

Joint Mobility

- ROM is maximum movement possible for joint - ROM varies and determined by: * Genetic makeup * Developmental patterns * Presence or absence of disease * Physical activity

Factors Influencing Activity and Exercise:

*Development Stages - Infants through school-aged children - Adolescence - Young to middle adults - Older adults *Environmental issues - Work site - Schools - Community *Cultural and ethnic influences *Family and social support *Behavioral aspects - Patients are more likely to incorporate an exercise program if those around them are supportive.

Distribution depends on:

- Circulation and how vascularized area is - Membrane Permeability - Protein Binding

Using a Metered Dose Inhaler

- Client teaching a client to use an MDI - Remove the mouthpiece cap - Exhale comfortably - Hold canister upside down - Press down once and inhale slowly and deeply through the mouth - Hold your breath for 10 seconds or as long as you can - Remove inhaler away from mouth - Exhale slowly through pursed lips - Repeat the inhalation if ordered - Rinse mouth with tap water - Clean MDI mouthpiece after each use

Dorsogluteal Site

- Close to the sciatic nerve and superior gluteal nerve - Complications occurred: * Numbness * Pain * Paralysis - More subcutaneous tissue - Use of dorsogluteal site should be removed from injection practice

Nursing Process: Assessment Urinary Elimination

- Consider Self-care ability, cultural considerations, and - Health Literacy - Nursing history - Physical assessment - Hydration status - Examination of urine - Relating data from diagnostic tests and procedures

Common bowel elimination problems

- Constipation - Impaction - Diarrhea - Incontinence - Flatulence - Hemorrhoids

Psychoneurologic System and exercise:

- Elevates mood - Relieves stress and anxiety - Improves quality of sleep for most individuals

Metabolic Changes with exercise:

- Elevates the metabolic rate - Decreases serum triglycerides and cholesterol - Stabilizes blood sugar and make cells more responsive to insulin • Increased basal metabolic rate • Increased use of glucose and fatty acids • Increased triglyceride breakdown • Increased gastric motility • Increased production of body heat

Isotonic Imbalances:

- Extracellular Fluid Volume Deficit - Extracelluar Fluid Volume Excess

Organs of Concern for Hygiene Care: The Feet

- Feet condition affects an individual's ability to walk. - Any injury or deformity interferes with mobility. - Foot care

Assessment of Urine

- Intake and Output - Characteristics of urine: * Volume * Ketone bodies * Color, clarity * Blood * Odor * Sterility * pH * Specific gravity * Glucose

Laboratory and Diagnostic Testing

- Label all specimens - Must be sent to lab within 2 hours - Standard precautions when handling specimens - Double voiding - Mid stream clean-catch urine specimen

Principles of Safe Patient Transfer and Positioning

- Mechanical lifts and lift teams are essential when a patient is unable to assist - When a patient is able to assist, remember the following: * The wider the base of support, the greater the stability of the nurse * The lower the center of gravity, the greater the stability of the nurse * The equilibrium of an object is maintained as long as the line of gravity passes through its base of support * Facing the direction of movement prevents abnormal twisting of the spine * Dividing balanced activity between arms and legs reduces the risk of back injury * Leverage, rolling turning, or pivoting requires less work than lifting * When friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it

Port a Cath

- Might be used for chemo, goes under the skin and you use a needle to access it. - Nice because you don't have to worry about it getting wet.

Nursing History in Urinary Elimination

- Normal voiding patterns - Appearance of urine - Recent changes - Past or current problems - Presence of urinary diversion - Factors influencing the elimination pattern

Pulse

- Palpable bounding of blood flow noted at various points on the body (never use thumb) - Indicator of circulatory status *Radial is most commonly used for pulse. Brachial artery used for BP

Implementation: Urinary Elimination

- Promoting fluid intake - Maintaining normal voiding patterns - Assisting with toileting - Preventing urinary tract infections - Managing urinary incontinence - Continence (bladder) training - Pelvic muscle exercises - Maintaining skin integrity - Applying external urinary drainage devices - Performing urinary catheterizations - Performing bladder irrigations - Providing care for clients with indwelling urinary catheters and urinary diversions - Patient Education

What is the skin responsible for?

- Protection - Secretion - Excretion - Temperature regulation - Sensation

Psychological Implications of Isolation

- Psychological implications - Isolation environment - Personal protective equipment - Specimen collection - Bagging of trash or linen - Patient transport - make sure patient has mask on for transport.

Physical illness and sleep:

- Respiratory disease—such as chronic obstructive pulmonary disease (COPD), emphysema, asthma, allergies, or the common cold—often interferes with sleep. - Connections between heart disease, sleep, and sleep disorders exist. Sleep-related breathing disorders are linked to increased incidence of nocturnal angina (chest pain), increased heart rate, electrocardiogram changes, high blood pressure, and risk of heart diseases and stroke. - Nocturia disrupts the sleep cycle. - Restless leg syndrome (RLS) can occur before sleep onset. RLS symptoms include recurrent, rhythmical movements of the feet and legs. Patients feel an itching sensation deep in the muscles. Relief comes only from moving the legs, which prevents relaxation and subsequent sleep. - Many adults in the United States have significant sleep problems from inadequacies in either the quantity or quality of their nighttime sleep and experience hypersomnolence on a daily basis.

Patients' Rights

- Right to be informed of medication - Right to refuse - Right to have a qualified nurse or MD - Right to be informed of experimental medication - Right to receive medication safely - Right to receive appropriate supportive therapy - Right to not receive unnecessary medicine - Right to be informed of medication that is part of research.

Nursing Diagnosis: The most common nursing diagnoses directly associated with safety concerns include:

- Risk for injury - Risk for falls - Risk for poisoning - Risk for infection - Risk for aspiration

Implementation - Dressings: Securing

- Tape - Ties - Binders

Selecting a Site

- The primary goal of site selection is to choose one that will be least vulnerable to infiltration as well as allow the patient the most freedom to continue with ADLs. - Start distal to proximal - Find a vein that is visible and palpable - Avoid areas of movement. Avoid areas of joint flexion. - Avoid area affected by mastectomy, CVA, or A-V fistula.

Implementation: Health Promotion: Routine Screening for Colorectal Cancer

- Third most common cancer in the US

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (Select all that apply.) 1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. 2. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. 3. The fat emulsion will help control hyperglycemia during periods of stress. 4. The parenteral nutrition will help your wounds heal. 5. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours.

1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. 3. The fat emulsion will help control hyperglycemia during periods of stress. 4. The parenteral nutrition will help your wounds heal.

What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

2. The antibiotics the patient has received are not strong enough to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

What is the most effective way to control transmission of infection? 1. Isolation precautions 2. Identifying the infectious agent 3. Hand hygiene practices 4. Vaccinations

3. Hand hygiene practices

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding

3. The amount of daily acetaminophen

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive compulsive behavior. 2. Personal preferences. 3. The patient's cultural norm. 4. Controlling behaviors.

3. The patient's cultural norm.

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage

3. Unstageable

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the health care provider about need for immunization. 4. Perform hand hygiene after care and/or handling contaminated equipment or material.

4. Perform hand hygiene after care and/or handling contaminated equipment or material.

Side effect

= Secondary effect - Unintended, usually predictable - May be harmless or harmful

Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? A. Comparing presuctioning and postsuctioning respiratory assessment data B. Confirming that the patient's pulse oximetry value is >90% C. Asking the patient to report any symptoms of dyspnea D. Assessing the patient's skin for signs of cyanosis

A. Comparing presuctioning and postsuctioning respiratory assessment data

Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient? A. Do not massage any reddened areas on the patient's skin. B. Be sure to wash the patient's face with soap. C. Disconnect the intravenous tubing when changing the gown. D. Wear gloves if necessary.

A. Do not massage any reddened areas on the patient's skin.

Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? A. Keep the hub parallel to the skin. B. Cleanse the site with an antibacterial swab. C. Cut the dressing to facilitate its removal. D. Turn the IV tubing roller clamp to the "off" position.

A. Keep the hub parallel to the skin. *Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient? A. Reposition the patient at least every 2 hours. B. Assess the patient's bony prominences every shift. C. Educate the family about the importance of healthy skin. D. Assist the patient in the selection of high-protein foods.

A. Reposition the patient at least every 2 hours.

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter? A. Wear clean gloves during care. B. Assess the patient's ability to provide self-care. C. Encourage the patient to report any pain originating from the catheter. D. Monitor the amount of urine in the drainage bag to prevent overflow.

A. Wear clean gloves during care.

Parasomnias

Are sleep problems that are more common in children. These include sleepwalking, night terrors, nightmares, bed-wetting, body rocking, and tooth grinding. When adults have these problems, it often indicates more serious disorders.

The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." What is the nurse's best response? A. "All right. Just holler when you're ready, and I'll come and help you get out of the tub." B. "Well, I'll check back with you in about 5 minutes to see if you need anything." C. "That's not safe. I'll wait right outside the door for you to finish." D. "I'll be back in 15 minutes. That should be enough time for you to finish up."

B. "Well, I'll check back with you in about 5 minutes to see if you need anything."

Which action would the nurse perform when preparing to suction a patient's oropharynx? A. Apply sterile gloves. B. Place the patient in a semi-Fowler's or sitting position. C. Remove the nasal cannula. D. Flush the suction catheter with 200 mL of warm tap water.

B. Place the patient in a semi-Fowler's or sitting position. A semi-Fowler's or sitting position would facilitate this intervention. This intervention would be performed using clean, not sterile, technique. The nasal cannula can remain in place to deliver oxygen during the intervention. Sterile water or sterile normal saline is preferred to tap water, and a quantity of only 100 mL is needed.

Implementation: Cleaning skin and drain sites

Basic Skin Cleaning - Clean from least contaminated to the surrounding skin - Use gentle friction - When irrigating, allow the solution to flow from the least to most contaminated area Irrigation - Wound irrigations

Which step to protect the patient from infection is of special concern when preparing a mini-infusion pump to deliver an analgesic? A. Ensure that the syringe is secure within the mini-infusion pump. B. Identify any history of allergic reaction to the prescribed analgesic. C. Use an antiseptic swab to wipe the proximal injection port on the primary tubing. D. Carefully depress the syringe plunger to fill the tubing with medication.

C. Use an antiseptic swab to wipe the proximal injection port on the primary tubing.

Kussmaul's respiration

Deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.

Excretion

Exit body through the kidneys, liver, bowel, lungs and exocrine glands.

Goal for Impaired Skin or Tissue Integrity

Goal: Pressure will be reduced to the sacral area, and the wound will show movement toward healing in 1 week. Expected outcomes - Wound will decrease in diameter in 7 days. - No evidence of further wound formation will be noted in 3 days.

Pyrexia (fever):

Important defense mechanism - Pyrogens - bacteria or virus - Febrile/afebrile - (febrile - having or showing symptoms of fever) - Fever of unknown origin (FUO)

Urinary Incontinence Associated with Chronic Retention of Urine (Overflow Urinary Incontinence)

Involuntary loss of urine caused by an overdistended bladder often related to bladder outlet obstruction or poor bladder emptying because of weak or absent bladder contractions

Evaluation is an ongoing process that involves collaboration with:

Patient, family, and multiple health care professionals to keep patients safe in health care agencies, community environments, and at home.

Infiltration

The diffusion or accumulation (in a tissue or cells) of foreign substances or in amounts in excess of the normal.

Arterial Blood Pressure

- Force exerted on the walls of an artery by pulsing blood under pressure from the heart. - Systolic = maximum peak pressure during ventricular contraction - Diastolic = minimal pressure during ventricular relaxation - Pulse pressure = Difference between systolic and diastolic pressures - Measured in mmHg - Recorded as a fraction: 120/80 - Systolic = 120, Diastolic = 80

Essential Parts of Medication Orders:

- Full name of client - Date and time the order is written - Name of the medication - Dosage - Frequency of administration - Route of administration - Route of administration - Time and frequency of administration - look at abbreviations because orders are written a certain way

Fluid Balance: Implementation

- Health promotion - Acute care

Nursing Process: Temperature: Implementation

- Health promotion - Acute care - Restorative and continuing care

Electrolyte Imbalances

- Hypokalemia - Hyperkalemia - Hypocalcemia - Hypercalcemia - Hypomagnesemia - Hypermagnesemia

Delegation of BP

- May be delegated to UAP - Nurse interprets abnormal readings and determines response

When to Assess Vital Signs

- On admission to obtain baseline - Change in client's health status - Client reports symptoms such as chest pain, feeling hot, or faint. - Before and after surgery/invasive procedure - Before and after medication administration that could affect respiratory or Cardiovascular system - Before, during and after nursing intervention that could affect vital signs. Ex. bedrest

Two types of canes, straight-legged and quad canes

- Straight-legged canes are more common and are used to support a patient with decreased leg strength - The quad cane provides the most support and is used when the patient has either partial or complete leg paralysis

Central sleep apnea (CSA) involves dysfunction in the respiratory control center of the brain.

- The impulse to breathe fails temporarily, and nasal airflow and chest wall movement cease. - The oxygen saturation of the blood falls. The condition is common in patients with brainstem injury, muscular dystrophy, and encephalitis. - Less than 10% of sleep apnea is predominantly central in origin. - People with CSA tend to awaken during sleep and therefore complain of insomnia and excessive daytime sleepiness (EDS). Mild and intermittent snoring is also present.

Psychosocial considerations for urinary elimination

- The process of urination is a private event and requires the nurse to be sensitive to the need for privacy. - Incontinence can be devastating to self-image. And self-esteem.

The process of urination depends on the effective functioning of:

- Upper urinary tract (kidneys, ureters) - Lower urinary tract (bladder, urethra, pelvic floor) - CV system - Nervous system

Name the three important dimensions to consistently measure to determine wound healing.

1. Width 2. Length 3. Depth

A health care provider ordered enalapril (Vasotec) 2 mg IV push for a patient with hypertension. The pharmacy sent vials marked 1.25 mg enalapril/mL. How many mL does the nurse administer? ___ mL

1.6 mL

What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing

2. Risk factors that place the patient at risk for skin breakdown

What would minimize the nurse's risk for contamination during the removal of a nasogastric tube? A. Wearing treatment gloves B. Providing the patient with an emesis basin C. Protecting the patient's chest with an absorbent towel D. Discarding any soiled tissues in the biohazard receptacle

A. Wearing treatment gloves

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? A. Taking the patient's temperature B. Applying clean gloves C. Assessing the wound for drainage D. Assessing the dressing for drainage

B. Applying clean gloves

When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again? A. Aspiration of blood prior to injecting the medication B. Inability to feel resistance when injecting the medication C. Formation of a 6-mm bleb at the injection site D. Appearance of a lesion resembling a mosquito bite at the injection site

B. Inability to feel resistance when injecting the medication *Lack of resistance as the intradermal medication is injected indicates that the needle is not in the dermal layer and must be repeated.

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? A. Ask the patient to cough. q C. Encourage the patient to swallow. D. Instruct the patient to hyperextend the neck.

B. Withdraw the tube to the nasopharynx. If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance. Coughing will not help remove the source of resistance; rather, it is an indication that the tube is misplaced. If the tube meets resistance, neither swallowing nor hyperextending the neck will help to advance it

Which patient should not have his or her feet soaked during a complete bed bath? A. A patient with arthritis B. A patient who has just complained of shoulder pain C. A patient with diabetes mellitus D. A patient who is nauseated

C. A patient with diabetes mellitus

Which action would decrease a patient's pain before a transfer with a hydraulic lift? A. Stop the transfer if the patient expresses or displays physical signs of pain. B. Explain the procedure to the patient before beginning the transfer. C. Administer a prescribed analgesic 30 to 60 minutes before the transfer. D. Postpone the transfer if the patient reports having physical pain or anxiety before the transfer.

C. Administer a prescribed analgesic 30 to 60 minutes before the transfer.

When instructing a patient in the use of a dry powder inhaler (DPI), which statement is accurate? A. It is important to shake the DPI before administering the medication. B. It is important to exhale while the lips are still around mouthpiece. C. It is important to read the manufacturer's instructions to determine how quickly to inhale the medication. D. It is important for the patient to hold his or her breath for at least 60 seconds after inhaling the medication.

C. It is important to read the manufacturer's instructions to determine how quickly to inhale the medication. * DPIs differ regarding how quickly the medication should be inhaled. The manufacturer's instructions should include this information. The DPI should not be shaken. The patient should be instructed to remove his or her lips from the mouthpiece as soon as the medication has been delivered. The patient should be instructed to hold his or her breath for at least 10 seconds.

Which action is part of the preparation for nasotracheal suctioning? A. Place the patient in a supine position. B. Preoxygenate the patient with 100% oxygen. C. Suction 100 mL of warm tap water to flush the suction catheter. D. Place water-soluble lubricant onto the open sterile catheter package.

D. Place water-soluble lubricant onto the open sterile catheter package. *Lubricant facilitates the insertion of the catheter. The patient should be in the semi-Fowler's position or sitting upright. Preoxygenation is not needed before nasotracheal suctioning. Sterile water or sterile normal saline is used to flush the catheter

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound? A. Remove the dressing, inspect the wound, and reapply a new dressing. B. Inspect the wound and reapply the surgical dressing every 2 hours. C. Inspect the wound, and keep the dressing off until the health care provider arrives. D. Wait until the health care provider orders the removal of the surgical dressing.

D. Wait until the health care provider orders the removal of the surgical dressing. *The nurse would want to wait until the provider orders the dressing to be removed to ensure that the initial dressing is ready to come off. The nurse would not remove an initial surgical dressing for direct wound inspection until the health care provider has written an order for its removal.

Sleep: Evaluating

Determine whether expected outcomes have been met. - Are you able to fall asleep within 20 minutes of getting into bed? - Describe how well you sleep when you exercise. - Does the use of quiet music at bedtime help you to relax? - Do you feel rested when you wake up?

Factors that affect sensory function: Amount of stimuli

Excessive stimuli in an environment causes sensory overload. The frequency of observations and procedures performed in an acute health care setting are often stressful. If a patient is in pain or restricted by a cast or traction, overstimulation frequently is a problem. In addition, a room that is near repetitive or loud noises (e.g., an elevator, stairwell, or nurses' station) contributes to sensory overload.

Isotonic

Expand intravascular volume - 0.9% NaCl (normal saline) - Lactated Ringers (a balanced electrolyte solution) - 5% Dextrose in water (D5W)

Nursing Process: Temperature: Evaluation

Get client's perspective, compare actual with expected outcomes, and determine whether goals were met.

Implementation - Dressings: Packing a Wound

Negative-pressure wound therapy

What is hemiplegia?

One-sided paralysis *Quad Cane provides most support and is used when there is partial or complete leg paralysis or some hemiplegia.

Shower:

Patient sits or stands under a continuous stream of water. The shower provides more thorough cleaning than a bed bath but can cause fatigue.

Risk Factors for Hygiene Care: Foot Problems

Patient unable to bend over or has reduced visual acuity ---> Patient is unable to fully visualize entire surface of each foot, impairing ability to adequately assess condition of skin and nails.

Centers for Medicare and Medicaid Services:

The federal organization that certifies all Medicare- and Medicaid-participating hospitals (facilities for acute care, psychiatric and rehabilitation services, and long-term care, as well as children's hospitals and treatment centers for alcohol and chemical dependence)

What is the procedure to obtain BP in lower extremity?

The procedure is identical to brachial artery auscultation. Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same

Performing Bladder Irrigation

To maintain the patency of indwelling urinary catheters, it is sometimes necessary to irrigate or flush a catheter with sterile solution. However, irrigation poses the risk for causing a UTI and thus must be done maintaining a closed urinary drainage system. Generally, if a catheter becomes occluded, it is best to change it rather than risk flushing debris into the bladder. In some instances the health care provider will determine that irrigations are needed to keep a catheter patent such as after genitourinary surgery when there is high risk for catheter occlusion from blood clots.

Drawing 2 insulins into one syringe.

Order: Regular 10 units; NPH 30 units - Inject air into vials - Always draw up Regular insulin FIRST - Then draw up NPH insulin last. - Always have a 2nd nurse check units of each insulin drawn. - DRAW CLEAR BEFORE CLOUDY!!!

Correcting Imbalances

Oral replacement - If client is not vomiting - If client has not experienced excessive fluid loss - Has intact GI tract and gag and swallow reflexes Restricted fluids may be necessary for fluid retention - Vary from nothing by mouth to precise amount ordered - Dietary changes

Temperature sites

Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery *Temporal artery, esophageal, pulmonary artery used in critical care

Some diagnoses that apply to patients with elimination problems include:

- Disturbed body image - Bowel incontinence - Constipation - Perceived constipation - Risk for constipation - Diarrhea - Nausea - Deficit knowledge (nutrition) - Constipation related to opiate-containing pain medication - Decreased mobility - Decreased food and fluid intake

What patient conditions are not appropriate for electronic BP measurement?

- If you have a code - If someone has parkinson's or something that makes them shake - Shivering - Irregular heart rate - Peripheral vascular obstruction - Seizures - Inability to cooperate - Blood pressure less than 90 mm Hg systolic - If someone is anemic, it might be hard for pulse ox to pick up oxygen saturation (can't get one with nail polish on fingers, need to make sure they have no nail polish, if there is nail polish, remove it).

Describe and demonstrate the following positioning techniques. Why is position used: Side-Lying position

- In the side-lying (or lateral) position the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. - A 30-degree lateral position is recommended for patients at risk for pressure ulcers. - Trunk alignment needs to be the same as in standing. - The patient needs to maintain the structural curves of the spine, the head needs to be supported in line with the midline of the trunk, and rotation of the spine needs to be avoided.

Incontinent Urinary Diversion Ureterostomy or Ileal Conduit

- Incontinent urinary diversion (less common) ureters connected to ileum with stoma, drains continuously (collection pouch). No sensation or control. - Continuous urine drainage collected in a pouch.

Respiratory Changes with exercise:

- Increase ventilation and oxygen intake improving gas exchange - Prevents pooling of secretions in the bronchi and bronchioles • Increased respiratory rate and depth followed by a quicker return to resting state • Improved alveolar ventilation • Decreased work of breathing • Improved diaphragmatic excursion

Factors Affecting Safety: The risk for injury is based on many internal and external factors.

- Individual * Body system integrity * Lifespan - Environmental * Pollution * Lighting * Communicable diseases * Workplace hazards - Patient safety concerns

The American Academy of Sleep Medicine developed the International Classification of Sleep Disorders version 2 (ICSD-2), which classifies sleep disorders into eight major categories.

- Individuals with sleep-related breathing disorders have changes in respirations during sleep. - Hypersomnias are sleep disturbances that result in daytime sleepiness and are not caused by disturbed sleep or alterations in circadian rhythms. - The circadian rhythm sleep disorders are caused by a misalignment between the timing of sleep and individual desires or the societal norm. - The parasomnias are undesirable behaviors that occur usually during sleep. - Sleep and wake disturbances are associated with many medical and psychiatric sleep disorders, including psychiatric, neurological, or other medical disorders. - In sleep-related movement disorders the person experiences simple stereotyped movements that disturb sleep. The category of isolated symptoms, apparently normal variants, and unresolved issues includes sleep-related symptoms that fall between normal and abnormal sleep. - The "other" sleep disorders category contains sleep problems that do not fit into other categories.

Critical Thinking with Bowel Elimination:

- Integrate the knowledge from nursing and other disciplines to understand the patient's response to bowel elimination alterations. - Experience in caring for patients with elimination alterations helps you provide an appropriate plan of care. - Use critical thinking attitudes such as fairness, confidence, and discipline. - Apply relevant standards of practice when selecting nursing measures.

Skeletal System: Joints

- Joints connect bones. - Classification of joints: Synostotic, cartilaginous, fibrous, synovial

Critical thinking requires synthesis of:

- Knowledge - Experience - Information gathered from patients - Critical thinking attitudes - Intellectual and professional standards

The Oral Cavity: Bucal Cavity

- Lips, cheek walls, tongue, palates, bucal glands - Sores, stomatitis (inflamed and sore mouth), halitosis (bad breath) - Lips: cheilosis (Inflammation and small cracks in one or both corners of the mouth) - Teeth: a set of 32: carries, periodonitis - Gums: normal is pink & moist: gingivitis; scurvy (vitamin C deficiency) - Tongue: dry, coated

Dreams

- Occur in NREM and REM sleep - Important for learning, memory, and adaptation to stress - Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe that they are functionally important to learning, memory processing, and adaptation to stress. - The ability to describe a dream and interpret its significance sometimes helps resolve personal concerns or fears. - Another theory suggests that dreams erase certain fantasies or nonsensical memories.

Urinary Elimination Changes with exercise:

- Promotes blood flow to the kidneys causing body wastes to be excreted more effectively - Prevents stasis (stagnation) of urine in the bladder

Factors that Influence Absorption

- Route of administration - Ability of medication to dissolve - Blood flow to the site - Body surface area - Lipid solubility of medication

Patient Hygiene Needs: Implementation

- Skin Care Guidelines: * Intact Skin * Moisture & bacteria * Body odor * Skin sensitivity * Skin cleaning agents - Bathing: * Type of bath to be rendered - Hair Care - Perineal/Genital Care - Oral Hygiene - Foot & Nail Care - Ear, Eye, Nasal Care

Body sites commonly used for subcutaneous injections.

- The best subcutaneous injection sites include the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. - The site most frequently recommended for heparin injections is the abdomen. - Alternative subcutaneous sites for other medications include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas. - The injection site you choose needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves.

IV Start Pain Management

- Topical anesthesia cream may be applied to site 1 hr. prior to stick. It might be a good idea to anesthetize a couple of sites. - Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer. *One of the most frequent contributors to patient dissatisfaction is painful phlebotomy and IV starts

When should an order be questioned?

- Unclear or illegible - Dosage range not in therapeutic range - Improbable or incorrect route - Medication could harm client - Client and/or family questions the medication

A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements

1. Cuff too small 5. Insufficient time between measurements

You apply topical medications to mucous membranes in the following ways:

1. Direct application of a liquid or ointment (e.g., eyedrops, gargling, or swabbing the throat) 2. Insertion of a medication into a body cavity (e.g., placing a suppository in rectum or vagina or inserting medicated packing into vagina) 3. Instillation of fluid into a body cavity (e.g., eardrops, nose drops, or bladder and rectal instillation [fluid is retained]) 4. Irrigation of a body cavity (e.g., flushing eye, ear, vagina, bladder, or rectum with medicated fluid [fluid is not retained]) 5. Spraying a medication into a body cavity (e.g., instillation into nose and throat)

What is your role as a nurse during a fire? (Select all that apply.) 1. Help to evacuate patients 2. Shut off medical gases 3. Use a fire extinguisher 4. Single carry patients out 5. Direct ambulatory patients

1. Help to evacuate patients 2. Shut off medical gases 3. Use a fire extinguisher 5. Direct ambulatory patients

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.) 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's skin dry. 5. The outer surface of the catheter is not considered sterile.

1. It allows migration of organisms into the bladder. 3. It obstructs the normal flushing action of urine flow.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed. 2. Place the patient in a belt restraint. 3. Provide one-on-one observation of the patient. 4. Apply wrist restraints.

1. Place a bed alarm device on the bed.

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient who has just been diagnosed as having tuberculosis 5. Decreasing a patient's environmental stimuli to decrease nausea

1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter

Which food item would not be given to a patient on a dysphagia diet? A. Egg salad sandwich on wheat bread B. Biscuits and gravy with scrambled eggs C. Chicken noodle soup D. Rice pudding

C. Chicken noodle soup All of the foods listed may be eaten by a patient on a dysphagia diet except the chicken noodle soup. The liquid portion of the soup is not viscous enough to form a soft bolus in the mouth.

The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? A. Reinstruct the patient in proper turning techniques. B. Document that the patient refuses to turn independently. C. Communicate that the staff must turn the patient after surgery. D. Restrict turning unless absolutely necessary.

C. Communicate that the staff must turn the patient after surgery.

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? A. Remove the wheelchair leg rests. B. Ask the patient to rate his or her pain level. C. Lower the foot rests, and place the patient's feet on them. D. Remove the transfer belt.

C. Lower the foot rests, and place the patient's feet on them. *The nurse lowers the foot rests and places the patient's feet on them once the patient has been positioned in the wheelchair. Doing so supports the patient's feet and keeps them from dragging and creating a falling hazard when the chair is moved.

What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection? A. Instruct the patient to relax. B. Insert the needle at a 45-degree angle. C. Pull back on the plunger after inserting the needle. D. Pull the skin taut at the injection site when inserting the needle.

C. Pull back on the plunger after inserting the needle. *Pulling back on the plunger will allow the nurse to determine if the needle is in a blood vessel, rather than in muscle tissue.

Maintaining the System

Changing intravenous fluid containers, tubing, and dressings - Assisting patient with self-care activities - Helping patients to Protect IV Integrity Complications - Fluid overload, infiltration, extravasation, phlebitis, local infection, bleeding at the infusion site Discontinuing peripheral IV access *Bag cannot be used more than 24 hours. As long as you are using same fluid, line only needs to be changed every 72 hours. IV site can be changed every 96 hours. Need doctors order to start and discontinue an IV

Abrasion

Scraping or rubbing away of epidermis that results in localized bleeding and later weeping of serous fluid - Be careful not to scratch patient with jewelry or fingernails. - Wash abrasions with mild soap and water; dry thoroughly and gently. - Observe dressing or bandage for retained moisture because it increases risk of infection.

Prescriptions:

The health care provider writes prescriptions for patients who are to take medications outside of the hospital. The prescription includes more detailed information than a medication order because the patient needs to understand how to take the medication and when to refill the prescription if necessary.

Assess for and correct any of the following potential trouble points with patients in the prone position:

• Neck hyperextension • Hyperextension of the lumbar spine • Plantar flexion of the ankles • Unprotected pressure points at the chin, elbows, female breasts, hips, knees, and toes

Infection Control: 3 Basic Principles

- Clean to clean - Dirty to dirty - Sterile to sterile

Korotkoff phases

*When it is finally silent, that is when you take your diastolic

Non-Luer-Lok syringe

- Has a smooth graduated tip - Needles are slipped onto it

2. The body alignment of the patient in the tripod position includes the following: (Select all that apply.) 1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees 4. Axillae resting on the crutch pads 5. Bent knees and hips

1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient? 1. An intestinal obstruction 2. Irritation of the intestinal mucosa 3. Gastroenteritis 4. A fecal impaction

1. An intestinal obstruction

What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture? A. Check the tube placement. B. Assess the pH of the contents. C. Notify the health care provider. D. Irrigate the tube with water.

C. Notify the health care provider. Coffee-grounds aspirate indicates bleeding. The health care provider should be notified.

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? (Select all that apply.) 1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if has trouble hearing 5. Look behind toward the blind spot 6. Stop driving at age 75

1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if has trouble hearing 5. Look behind toward the blind spot

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy

1. Encouraging use of an overhead trapeze for positioning and transfer

A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use? 1. Four-point 2. Three-point 3. Two-point 4. Swing-through

1. Four-point

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1. Debridement

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? 1. Record the amount and continue to monitor drainage. 2. Notify the physician. 3. Strip the chest tube starting at the chest. 4. Increase the suction by 10 mm Hg.

1. Record the amount and continue to monitor drainage.

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension

1. Thrombus formation 2. Increased cardiac workload 5. Orthostatic hypotension

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs

2. Assess the intake and output from system

A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? 1. Institute isolation precautions 2. Clean the central line port through which the TPN is infusing with antiseptic 3. Change the TPN tubing every 24 hours 4. Monitor glucose levels to watch and assess for glucose intolerance

2. Clean the central line port through which the TPN is infusing with antiseptic

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? 1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy

2. Frequent change of position

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2. Hanging the urinary drainage bag below the level of the bladder

An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence

2. Dehydration

Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

2. Difficulty arousing the patient

Which patient is at highest risk for tachycardia? 1. A healthy basketball player during warmup exercises 2. A patient admitted with hypothermia 3. A patient with a fever of 39.4° C (103° F) 4. A 90-year-old male taking beta blockers

3. A patient with a fever of 39.4° C (103° F)

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1. Contact the nursing supervisor. 2. Restrict the family's visiting privileges. 3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 5. Thank the family for being conscientious and put the four rails up. 6. Discuss alternatives that are appropriate for this patient with the family.

3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 6. Discuss alternatives that are appropriate for this patient with the family.

Which nursing intervention is most important when caring for a patient with an ileostomy? 1. Cleansing the stoma with hot water 2. Inserting a deodorant tablet in the stoma bag 3. Selecting or cutting a pouch with an appropriate-size stoma opening 4. Wearing sterile gloves while caring for the stoma

3. Selecting or cutting a pouch with an appropriate-size stoma opening

What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment? 1. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks 2. Use diapers and heavy padding on the bed 3. Initiate bowel or habit training program to promote continence 4. Help the patient to toilet once every hour

3. Initiate bowel or habit training program to promote continence

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? 1. Recheck by performing another blood glucose test. 2. Call the primary health care provider. 3. Check the medical record to see if there is a medication order for abnormal glucose levels. 4. Monitor and recheck in 2 hours.

3. Check the medical record to see if there is a medication order for abnormal glucose levels.

The patient reports episodes of sleepwalking to the nurse. Through understanding of the sleep cycle, the nurse recognizes that sleepwalking occurs during which sleep phase? 1. Rapid eye movement (REM) sleep 2. Stage 1 nonrapid eye movement (NREM) sleep 3. Stage 4 NREM sleep 4. Transition period from NREM to REM sleep

3. Stage 4 NREM sleep

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants

3. Stool softeners

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine

3. Light pink urine

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3. Explain the reasons for isolation procedures and provide meaningful stimulation.

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. A nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider 2. Record in medical record 3. Decrease the IV flow rate 4. Discontinue the IV site

3. Decrease the IV flow rate

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? 1. Coughing up sputum occasionally 2. Coughing up thin, watery sputum after nebulization 3. Decreased ability to clear airway through coughing 4. Lung sounds clear only after coughing

3. Decreased ability to clear airway through coughing

Which of the following are physiological outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand

3. Decreased lung expansion

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine?

3. Do you dribble urine constantly?

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? 1. The patient is 5 feet 6 inches and weighs 120 lbs. 2. The patient speaks and understands English. 3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation. 4. The patient received analgesia for pain 30 minutes ago.

3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place

3. Washing with soap and water before applying the condom-type catheter

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line 3. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool

4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool

For which of the following health problems is a patient who has a 40-year history of smoking at risk? 1. Alcoholism and hypertension 2. Obesity and diabetes 3. Stress-related illnesses 4. Cardiopulmonary disease and lung cancer

4. Cardiopulmonary disease and lung cancer

Which assessment does a nurse interpret as a transfusion reaction? 1. Crackles in dependent lobes of lungs 2. High fever, severe hypotension 3. Anxiety, itching, confusion 4. Chills, tachycardia, and flushing

4. Chills, tachycardia, and flushing

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 3. Difficulty swallowing 4. Left ankle joint stiffness

4. Left ankle joint stiffness

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? 1. Increased breathlessness but increased activity tolerance 2. Decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness

4. Decreased activity tolerance and increased breathlessness

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 112 3. Respiratory rate: 24 4. Oxygen saturation: 96% 5. Blood pressure: 134/78

4. Oxygen saturation: 96%

Factors that affect sensory function: Environmental factors

A person's occupation places him or her at risk for hearing, visual, and peripheral nerve alterations. Individuals who have occupations involving exposure to high noise levels (e.g., factory or airport workers) are at risk for noise-induced hearing loss and need to be screened for hearing impairments.

Disinfection

A process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects: - Disinfection of surfaces - High-level disinfection, which is required for some items such as endoscopes

Standing order

A standing order is carried out until the health care provider cancels it by another order or a prescribed number of days elapse.

A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? A. Drainage that was not present previously B. Redness at the abdominal suture line C. Granulation tissue in the wound bed D. The patient reports less pain

A. Drainage that was not present previously

Tachypnea

Abnormally rapid breathing. More than 20 breaths per minute

Advantages and Disadvantages of Temporal Artery Temperature Measurement Sites

Advantages: - Easy to access without position change - Very rapid measurement - Comfortable with no risk of injury to patient or nurse - Eliminates need to disrobe or be unbundled - Comfortable for patient - Used in premature infants, newborns, and children - Reflects rapid change in core temperature - Sensor cover not required Disadvantages: - Inaccurate with head covering or hair on forehead - Affected by skin moisture such as diaphoresis or sweating

Diarrhea

An increase in the number of stools and the passage of liquid, unformed feces

Hesitancy

Delay in start of urinary stream when voiding

Crystalloids

Electrolytes - fluid .9% sodium chloride, 5% dextrose

Full-thickness wounds:

Extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location

Dry Skin

Flaky, rough texture on exposed areas such as hands, arms, legs, or face - Bathe less frequently. Rinse body of all soap because residue left on skin can cause irritation and breakdown. - Add moisture to air with use of humidifier. - Increase fluid intake when skin is dry. - Use moisturizing cream to aid healing. (Cream forms protective barrier and helps maintain fluid within skin.) - Use creams to clean skin that is dry or allergic to soaps and detergents.

Sleep: Planning

Goals and outcomes example - Follow professional standards - Create a concept map - Collaborate Setting priorities - Frequently sleep disturbances are the result of other health problems Teamwork and collaboration - Partner closely with the patient and sleep partner

Planning

Goals and outcomes: plan interventions according to - Risk for pressure ulcers - Type and severity of the wound - Presence of complications Setting priorities - Preventing pressure ulcers - Promoting wound healing Teamwork and collaboration

Assessment of Diffusion and Perfusion

Measurement of arterial oxygen saturation (SaO2), the percent of hemoglobin that is bound with oxygen in the arteries - Usually 95% to 100% - Pulse oximeter - Probes: digit, earlobe, disposable *We are measuring arterial oxygen saturation, not venal.

Hyperventilation

Occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood.

Extravasation

Occurs when there is accidental infiltration of a vesicant or chemotherapeutic drug into the surrounding IV site. Vesicants can cause tissue destruction and / or blistering.

Bleeding at venipuncture site

Oozing or slow, continuous seepage of blood from venipuncture site Assessment Findings: Fresh blood evident at venipuncture site, sometimes pooling under extremity Nursing Interventions: - Assess if IV system is intact. - If catheter is within vein, apply pressure dressing over site or change dressing. - Start new IV line in other extremity or proximal to previous insertion site if VAD is dislodged, IV is disconnected, or bleeding from site does not stop.

Infants, Toddlers, Preschoolers:

Prolonged immobility delays, gross motor skills, intellectual development, or musculoskeletal development

Sepsis

Rapid onset of chills, high fever, severe hypotension, and circulatory shock * May occur: Vomiting, diarrhea, sudden oliguria (acute kidney injury), disseminated intravascular coagulation (DIC) Causes: Bacterial contamination of transfused blood components

Purpose of Nephrostomy

Tubes are placed to drain renal pelvis when the ureter is obstructed

Pronation

Turning the forearm so the palm is down

Supination

Turning the forearm so the palm is up

Oral

The oral route is the easiest and the most commonly used route of medication administration. Medications are given by mouth and swallowed with fluid. Oral medications have a slower onset of action and a more prolonged effect than parenteral medications. Patients generally prefer the oral route.

What is the largest organ in the body?

The skin - It reflects changes in physical condition

Promoting Meaningful Stimulation: Hearing

To maximize residual hearing function, work closely with a patient to suggest ways to modify the environment. Patients can amplify the sound of telephones and televisions. An innovative way to enrich the lives of patients with hearing impairments is recorded music. Some patients with severe hearing loss are able to hear music recorded in the low-frequency sound cycles. One way to help an individual with a hearing loss is to ensure that the problem is not impacted cerumen. With aging cerumen thickens and builds up in the ear canal. Excessive cerumen occluding the ear canal causes conductive hearing loss. Instilling a softening agent such as 0.5 to 1 mL of warm mineral oil into the ear canal followed by irrigation of a solution of 3% hydrogen peroxide in a quart of warmed water removes cerumen and significantly improves a patient's hearing ability

Hypernatremia

Too much sodium

Performing Urinary Catheterization: When cleaning the urinary meatus, move the swab ________

downward

Immune System and exercise:

- Pumps lymph fluid from tissues into lymph capillaries and vessels - Increases circulation through lymph nodes - Strenuous exercise may reduce immune function: leaving window of opportunity for infection during recovery phase

Documentation of BP:

- Document in client's record - Document and record pertinent data - RA- right arm - RL- right leg - LA - left arm - LL - left leg - Ex. 126/80, sitting, LA, Prehypertension

Documentation of respirations:

- Document in client's record - Document the RR, Depth, Rhythm, character - Example: RR = 18, Depth = normal, Rhythm = regular, character = no adventitious sounds. *Character describes nature of sound. Breathing should be silent. So if you heart wheezing and stuff, document.

Recent National Patient Safety Goals include:

- Identify patients correctly. - Improve staff communication. - Use medicines safely. - Use alarms safely. - Prevent infection. - Identify patient safety risks. - Prevent mistakes in surgery.

Cardiac output in effected by:

- Peripheral resistance - Blood volume - Viscosity - Elasticity

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake

4. Use of incentive spirometer every 2 hours while awake

Place the steps for an ostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1 5. Remove the old pouch. 8. Cleanse and dry the peristomal skin. 7. Assess the stoma and the skin around it. 2. Measure the stoma. 6. Trace the correct measurement onto the back of the wafer. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 1. Close the end of the pouch.

Corns

Friction and pressure from ill-fitting or loose shoes cause keratosis. It is seen mainly on or between toes, over bony prominence. Corn is usually cone shaped, round, and raised. Soft corns are macerated. - Pain is aggravated when wearing tight shoes. Tissue becomes attached to bone if allowed to grow. Resultant pain causes an alteration in gait.

Nursing Process: Temperature: Planning

Goals and Outcomes

Contact Dermatitis

Inflammation of skin characterized by abrupt onset with erythema; pruritus; pain; and appearance of scaly, oozing lesions (seen on face, neck, hands, forearms, and genitalia)

Infection

The invasion of a susceptible host by pathogens or microorganisms; results in disease.

The following are some common trouble areas for patients in the supine position:

• Pillow at the head that is too thick, increasing cervical flexion • Head flat on the mattress • Shoulders unsupported and internally rotated • Elbows extended • Thumb not in opposition to the fingers • Hips externally rotated • Unsupported feet • Unprotected pressure points at the occipital region of the head, vertebrae, coccyx, elbows, and heels

Osmolality Imbalances:

Hypernatremia Hyponatremia

Luer-Lok syringe

Requires the needle to be twisted onto it

Bioterrorism

The deliberate release of biologic agents such as bacteria, viruses, and other microbes to cause illness or kill people, animals, or plants

Polyuria

Voiding excessive amounts of urine

Frequency

Voiding more than 8 times during waking hours and/or at decreased intervals such as less than every 2 hours.

Fluid output:

- Fluid is lost through kidneys, skin, lungs, and GI tract - Insensible loss - breathing, fever - Sensible loss - things that you can notice, sweating, peeing

Health promotion

- Fluid replacement education - Teach patients with chronic conditions about risk factors and signs and symptoms of imbalances.

What are acceptable vital sign ranges for an adult?

Depends on the individual. Baseline can differ person to person.

Logrolling: Describe the procedure and give rationales.

(1) Place patient in supine position on side of bed opposite direction to be turned. (Prepares patient for turning onto side.) (2) Place small pillow between patient's knees. (Prevents tension on spinal column and adduction of hip.) (3) Cross patient's arms on chest. (Prevents injury to arms.) (4) Position two nurses or other staff members on side of bed to which patient will be turned. Position third nurse or staff member on other side of bed. If needed, four nurses are used; fourth nurse stands on same side as third nurse. (Distributes weight equally among nurses.) (5) Fanfold or roll drawsheet alongside of patient. (Provides strong handles to grip the drawsheet or pull sheet without slipping.) (6) With one nurse grasping drawsheet at lower hips and thighs and the other nurse grasping drawsheet at patient's shoulders and lower back, roll patient as one unit in a smooth, continuous motion on the count of three. (This maintains proper alignment by moving all body parts at the same time, preventing tension or twisting of the spinal column.) (7) Nurse on opposite side of bed places pillows along length of patient (Pillows keep patient aligned.) (8) Gently lean patient as a unit back toward pillows for support (Ensures continued straight alignment of spinal column, preventing injury.)

Psychoneurologic System and immobility:

- Decline in mood elevating substances - Perception of time intervals deteriorates - Problem-solving and decision-making abilities may deteriorate - Loss of control over events can cause anxiety

Older adults:

- Decreased physical activity - Hormonal changes - Bone reabsorption

Respiratory Changes with immobility:

- Decreased respiratory movement - Pooling of respiratory secretions - Atelectasis - Hypostatic pneumonia

Adolescents:

- Delayed in gaining independence and in accomplishing skills - Social Isolation can occur

Complications of IV Therapy

*Circulatory overload of IV Solution *Infiltration or Extravasation *Phlebitis *Local infection *Bleeding at venipuncture site

Which of the following represents the appropriate nursing management of a client wearing a condom catheter? a. Ensure that the tip of the penis fits snugly against the end of the condom. b. Check the penis for adequate circulation 30 minutes after applying. c. Change the condom every 8 hours. d. Tape the collecting tube to the lower abdomen.

- A 1-in. space should be left between the penis and the end of the condom. - Correct. The penis and condom should be checked one-half hour after application to ensure that it is not too tight. - The condom is changed every 24 hours. - The tubing is taped to the leg or attached to a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh.

Sleep deprivation

- A problem many patients experience as a result of dyssomnia. Causes include fever, difficulty breathing, pain, emotional stress, medications, and disturbances in the health care setting. Owing to long work schedules and rotations, health care providers are prone to sleep deprivation. Hospitalization makes patients prone to sleep deprivation caused by environmental noises and interruptions for care.

List and describe how to prevent thrombus formation.

- A prophylaxis program begins with identification of patients at risk and continues throughout their immobilization. - There are nursing interventions you can employ to reduce the risk of thrombus formation in immobilized patients. - Early ambulation; leg, foot, and ankle exercises; regularly provided fluids; frequent position changes; and patient teaching need to begin when a patient becomes immobile - Prophylaxis also includes anticoagulation, mechanical prevention with graduated compression stockings, intermittent pneumatic compression devices, and foot pumps. - Proper positioning reduces a patient's risk of thrombus formation because compression of the leg veins is minimized. - Instruct the family, patient, and all health care personnel not to massage the area because of the danger of dislodging the thrombus. - ROM exercises reduce the risk of contractures and aid in preventing thrombi.

Describe the use of the following with rationale(s): Trochanter roll

- A trochanter roll prevents external rotation of the hips when a patient is in a supine position. - To form a trochanter roll, fold a cotton bath blanket lengthwise to a width that extends from the greater trochanter of the femur to the lower border of the popliteal space. - Place the blanket under the buttocks and roll it counterclockwise until the thigh is in neutral position or inward rotation. - When the hip is aligned correctly, the patella faces directly upward. - Use sandbags in place of or in addition to trochanter rolls. - Sandbags are sand-filled plastic tubes or bags that are shaped to body contours.

Preparing Medications from Ampules

- A. Breaking the neck of an ampule using a gauze pad - B. breaking the neck of an ampule using an ampule opener. - Withdrawing a medication from A. an ampule on a flat surface - Withdrawing a medication from B. from an inverted ampule.

Saline Lock/Heparin Lock/Med Lock

- Abbreviated as SL or HL or ML - An IV site that is not being used, so it is kept "plugged" with a male adapter - IV is flushed with saline or heparin, according to hospital policy, to keep site patent (open)

Acute Adverse Effects of Transfusions:

- Acute intravascular hemolytic - Febrile non-hemolytic (most common) - Mild Allergic - Anaphylactic - Circulatory Overload - Sepsis **STOP THE INFUSION and send everything back to the blood bank and then start a new bag of 0.9% normal saline at KVO (Keep vein open) - stay with patient to make sure that they are ok.

General Nursing Responsibilities: Oral Meds

- Administer GI-irritating meds ac or pc - For an oral liquid that works on mucous membranes, do not follow with a "chaser" - Give unpleasant oral liquids cold or at room temperature - Give teeth-staining meds via straw - Position client upright to swallow - Ascertain that med has been consumed

Implementation - Dressings: Comfort Measures

- Administer analgesic medications 30 to 60 minutes before dressing changes - Carefully remove tape - Gently clean wound edges - Carefully manipulate dressings and drains to minimize stress on sensitive tissues - Turn and position patient carefully

Factors Affecting Bowel Elimination

- Age - Diet - Fluid intake - Physical activity - Psychological factors - Personal habits - Position during defecation - Pain - Pregnancy - Surgery and anesthesia - Medications - Diagnostic tests

Factors Affecting Body Temperature

- Age - Exercise - Hormonal level - Environment - Circadian rhythm - Temperature alterations *Smoking causes vasoconstriction which decreases temp of your skin **A 75 year old person is at risk for hypothermia because of lack of activity, nutrition, body regulation, skin

List five major factors that affect sensory function.

- Age - Meaningful stimuli - Amount of stimuli - Social interaction - Environmental factors

Factors influencing infection prevention and control:

- Age - Nutritional status - Stress - Disease process - Treatments or conditions that compromise the immune response

Factors Affecting Pulse

- Age - Sex - Exercise - increase - Fever - increase - Medications - Hypovolemia/dehydration - Stress - Position - Pathology

Factors affecting blood pressure:

- Age - Stress - Ethnicity - Gender - Daily variation - Activity, weight - Medications - Smoking

Diabetes Mellitus

- Along with diet, glucose monitoring, and medication, exercise is an important component in the care of patients with diabetes mellitus. - Individuals with type 1 diabetes need to exercise because it leads to improved glucose control, cardiovascular fitness, and psychological well-being. - Exercise lowers blood sugar levels, and the effects of exercise on blood sugar levels often last for at least 24 hours.

Preventing IV Infections

- Always use Standard Precautions - Change IV sites and tubing as per hospital policy - Use a new catheter for each insertion attempt - Change tubing immediately if contaminated - Fluids should not hang longer than 24 hours - Remove catheter as soon as no longer clinically needed (need MD order) - Clean ports with alcohol or chlorhexidine - Never disconnect tubing - Wash hands prior to and after handling IV system - Do not write directly on IV bags with pens/markers because ink could contaminate solution.

Medications that assist with urinary elimination:

- Antimuscarinics: For urgency, frequency, nocturia, and urgency UI - Bethanechol: Urinary retention - Tamsulosin and silodosin: For men with outlet obstruction caused by an enlarged prostate - Finasteride and dutasteride: Shrink the prostate - Antibiotics *Be familiar with the medications and indications for all medications your patient is taking!

Nursing Diagnosis in relation to medication administration

- Anxiety - Ineffective Health Maintenance - Deficient Knowledge (Medication self-administration) - Noncompliance (Medications) - Impaired swallowing - Impaired memory - Caregiver role strain (Caregiving Activities)

UAP should be instructed in the following when restraints are involved:

- Appropriate placement of restraints and reason for applying restraints - Appropriate use and type of restraint equipment - Appropriate assessment and documentation in accordance with institution policy - Ethical standards and basic therapeutic communication

Identify client before administering the medication

- Ask client to state their name and date of birth - Check armband - Check photo on chart (if available, i.e. in Long Term Care Facility)

Guidelines for elastic stocking application include:

- Assessing skin integrity of patent. - Turn stocking inside out. - Place toes into foot of stocking - Slide stocking over foot and rest of leg.

Implementation: Heat and Cold Therapy

- Assessment for temperature tolerance - Bodily responses to heat and cold - Local effects of heat and cold: * Effects of heat application * Effects of cold application - Factors influencing heat and cold tolerance: * Exposure time * Exposed skin * Temperature * Age * Perception of sensory stimuli - Application of heat and cold therapies: * Choice of moist or dry * Warm, moist compresses * Warm soaks * Sitz baths * Commercial hot and cold packs * Cold, moist, and dry compresses * Cold soaks * Ice bags or collars

Nursing Process: Assessment

- Assessment includes a thorough investigation: * Defense mechanisms, susceptibility, and knowledge of how infections are transmitted * Review of systems, travel history * Immunizations and vaccinations - Early recognition of risk factors - See through the patient's eyes. - Status of defense mechanisms - Patient susceptibility * Medical therapy - Clinical appearance * Signs and symptoms of infection * Laboratory data - i.e. increased WBCs

Inserting Rectal Suppository

- Assist client to left lateral or left Sims' position - Upper leg flexed - Expose the buttocks - Put a glove on the hand used to insert the suppository - Unwrap the suppository - Lubricate the smooth rounded end - Lubricate the glove index finger - Encourage the client to relax by breathing through the mouth - Insert the suppository gently into the anal canal - Avoid embedding in feces - Press buttocks together for a few minutes - Ask client to remain in the left lateral or supine position for at least 5 minutes

Piggybacks (IVPB)

- Based on physics gravity theory - Higher bag (Medication) will flow first - Lower bag will start (IV solution) when "piggybacked" bag is empty - Can do via a pump or gravity drip

Eye Care:

- Basic Eye Care - Contact Lens Care - Eyeglass Care - Prosthetic Eye Care

Check a medication against the order three times

- Before removing from the drawer - After removing from the container - Before opening the package at bedside OR - Before returning to the drawer

Blood Transfusion

- Blood component therapy = IV administration of whole blood or blood component - Blood groups and types - Autologous transfusion (collection and reinfusion of own blood) - Transfusing blood - Transfusion reactions and other adverse effects

Four Basic Elements of Normal Movement:

- Body alignment (posture) - Joint mobility - Balance - Coordinated movement

Alterations in Breathing Pattern

- Bradypnea* - Tachypnea* - Hyperpnea - Apnea* - Hyperventilation* - Hypoventilation* - Cheyne-Stokes respiration - Kussmaul's respiration - Biot's respiration

What is the importance of assessing gait when assessing for mobility?

- By assessing gait, you can draw conclusions about balance, posture, and the ability to walk without assistance, all of which affect the risk for falling. - To protect the patient's safety assessment flows like this: * Starts while the patient is lying * Proceeds to assessing sitting positions in bed * Transfers to chair * Finally walking - You move from most supportive position and gradually increase to higher levels to get an assessment of tolerance while maintaining patient safety

Which part of the stethoscope can you use to get BP?

- Can use the bell or diaphragm *Bell picks up low frequency sounds better. **Want to make sure that each pulse on each radial is equal if you don't have a baseline.

Mechanical Aides for Walking

- Cane - Walker - Crutches

Types of Drug Preparations

- Caplet, capsule, tablet - Cream, ointments, salves - Lotion, liniment - Syrup, elixir, extract - Suppository - Transdermal Patch - Paste - Sprays, Foams

Coronary Heart Disease:

- Cardiac rehabilitation is an integral part of comprehensive care of patients diagnosed with CHD. - Patients with CHD benefit from exercise and activity in terms of reduced mortality and morbidity, improved quality of life, improved left ventricular function, increased functional capacity, decreased blood lipids and apolipoproteins (protein components of lipoprotein complexes), and psychological well-being

Continuing and Restorative Care Given For:

- Care of ostomies: Patients with temporary or permanent bowel diversions have unique elimination needs. An individual with an ostomy wears a pouch to collect effluent or output from the stoma. The pouches are odor proof and have a protective skin barrier surrounding the stoma. Empty the pouch when it is image to image full. Change the pouching system approximately every 3 to 7 days, depending on a patient's individual needs. Assess the stoma color. It should be pink or red. You observe the skin at each pouch change for signs of irritation or skin breakdown. - Pouching ostomies: An ostomy requires a pouch to collect fecal material. An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. A person wearing a pouch needs to feel secure enough to participate in any activity - Nutritional considerations: After surgery it usually takes a few days for patients with new ostomies to feel that their appetite has returned to normal. Small servings of soft foods are typically more appetizing as they would be for any patient who has had an abdominal surgery. Patients with colostomies have no diet restrictions other than the diet discussed for normal healthy bowel function, with adequate fiber and fluid to keep the stool softly formed. Patients with ileostomies digest their food completely but lose both fluid and salt through their stoma and need to be sure to replace this to avoid dehydration. - Psychological Considerations - Bowel training: The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, a patient may establish a normal defecation pattern. The program requires time, patience, and consistency. - Maintenance of proper fluid and food intake - Promotion of regular exercise - Management of the patient with fecal incontinence or diarrhea - Maintenance of skin integrity

Nursing History should be organized around factors that affect elimination:

- Determination of the usual elimination pattern - Patient's description of usual stool characteristics - Identification of routine followed to promote bowel elimination - Presence and status of bowel diversions - Changes in appetite - Diet history - Description of daily fluid intake - History of surgery or illnesses affecting the GI tract - Medication history

Measurement of Blood Pressure

- Direct (Invasive monitoring) - Indirect * Ausculatory - listening with stethoscope * Palpatory - Sites * Upper arm (brachial artery) * Thigh (popliteal artery)

Musculoskeletal Sytem: Immobility

- Disuse osteoporosis - Disuse atrophy - Contractures - Stiffness and pain in the joints

Nasogastric/Gastrostomy Tube Medication Administration

- Check with pharmacist for a liquid form - Check to see if medication can be crushed - Crush a tablet into a fine powder and dissolve in at least 30 mL of warm water - Open capsules and mix the contents with water only with the pharmacists advice - Do not administer whole or undissolved medications - Assess tube placement - Aspirate stomach contents and measure the residual volume - Check agency policy if residual volume is greater than 100mL - Remove the plunger from the syringe - Connect syringe to a pinched or kinked tube - Put 15 - 30 mL (5 - 10 mL for children) of water into the syringe barrel to flush the tube - Pour liquid or dissolved medication into the syringe barrel and allow to flow by gravity into the enteral tube - Administer each medication separately and flush in between with 15-30 mL of tap water between each medication - After administration of all medications, flush with another 15-30 mL (5-10mL for children) of warm water to clear the tube - If the tube is connected to suction, disconnect the suction and keep the tube clamped for 20-30 minutes to enhance absorption

Physiology of Sleep

- Circadian rhythms: affected by light, temperature, social activities, and work routines. - The biological rhythm of sleep frequently becomes synchronized with other body functions. - People experience cyclical rhythms as part of their everyday lives. - The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm. - The suprachiasmatic nucleus (SCN) nerve cells in the hypothalamus control the rhythm of the sleep-wake cycle and coordinate this cycle with other circadian rhythms. - Circadian rhythms influence the pattern of major biological and behavioral functions. The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24-hour circadian cycle. - All persons have biological clocks that synchronize their sleep cycles. This explains why some people fall asleep at 8 p.m., whereas others go to bed at midnight or early in the morning. Different people also function best at different times of the day. - Failure to maintain an individual's usual sleep-wake cycle negatively influences the patient's overall health.

Safety Guidelines for Skills

- Cleaning devices between clients decreases risk for infection - Rotate sites for repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown. - Analyze trends for vital signs, and report abnormal findings. - Determine the appropriate frequency of measuring vitals signs based on the client's condition.

Clinical Indications of Parenteral Nutrition

- Client cannot tolerate internal nutrition as in case of paralytic ileus, intestinal obstruction, persistent vomiting. - Client with hyper-metabolic status as in case of burns and cancer. - Client at risk of malnutrition because of recent weight loss of > 10%, NPO for > 5 days, and preoperative for severely depleted clients.

Subcutaneous Injections

- Commonly used for insulin and heparin - Use 5/8 - ½", 25 to 27 gauge needle - For insulin use only insulin syringe: 50 units or 100 unit syringe. - Average size client, pinch skinfold and inject at 45-degree angle (pinch 1" - 45 degree) OR pinch 2" skinfold - 90 degree angle.

Promoting Fluid and Electrolyte Balance

- Consume adequate fluid intake - Avoid foods with excess salt, sugar, caffeine - Eat well-balanced diet - Limit alcohol intake - Increase fluid intake before, during, after strenuous exercise - Replace lost electrolytes - Maintain normal body weight - Learn about, monitor, manage side effects of medications - Recognize risk factors - Seek professional health care for notable signs of fluid imbalances

What are some pathological conditions that can affect body alignment, mobility, and activity?

- Coronary Heart Disease - Hypertension - COPD - Diabetes Mellitus

Medication Administration Nursing Responsibilities

- Correctly calculate medication dosages - Know conversion factors - Watch decimal points and zeros - Correctly administer medications - Only administer medications that YOU prepare. - Adheres to the "6" rights of Medication Administration

Delegation of respirations:

- Counting and observing respirations may be delegated to UAP. - Nurse interprets abnormal respirations and determines response.

Common Errors in Blood Pressure Assessment

- Cuff too wide = false low reading - Cuff too narrow = false high reading - Cuff too loose = false high reading - Deflating too slow = false high diastolic reading - Deflating too fast = false low systolic and false high diastolic reading - Inflating too slow = false high diastolic reading *If you don't take the BP correctly, you will not get a correct reading

Culturally congruent care modes actions:

- Cultural care preservation - Cultural care accomodation - Cultural care repatterning or restructuring

Routine Catheter Care

- Daily routine perineal care - Perineal care after bowel movement - Empty drainage bags when ½ full.

Fluid Balance - Physical Assessment:

- Daily weights * Indicator of fluid status * Use same conditions to weigh - Fluid intake and output (I&O) * 24-hour I&O: compare intake versus output * Intake includes all liquids eaten, drunk, or received through IV * Output = Urine, diarrhea, vomitus, gastric suction, wound drainage - Laboratory studies

What is the function of the kidneys?

- Filter metabolic waste, toxins, excess ions & water from blood and excreted as water. - Regulates: blood volume, BP, electrolyte levels, acid-base balance.

Central Line Teaching

- Do not allow anyone to take a blood pressure on the arm a PICC line is inserted. - Wear a medic-alert bracelet if the device is to be in for a long period of time. - For a PICC, you do not need to restrict activities. Showering is allowed if site is kept dry. - Implanted venous device there are no restrictions.

Documentation of pulse:

- Document in client's record - Use a graphic sheet - Document the pulse rate, rhythm, and volume - Variation in pulse rate - Abnormal skin color and temperature - Ex: Pulse = 90 bpm, Rhythm = regular, Volume or strength = +2 (normal & expected). *Use 0-3 0 = pulse is absent 1+ = diminished 2+= Brisk and what is expected 3+= Full volume is bounding. Not easily obliterated when you press down on radial artery

Hygiene Schedules:

- Early Morning Care: Nursing personnel on the night shift provide basic hygiene to patients getting ready for breakfast, scheduled tests, or early morning surgery. "AM care" includes offering a bedpan or urinal if the patient is not ambulatory, washing the patient's hands and face, and helping with oral care. - Routine Morning Care: After breakfast help by offering a bedpan or urinal to patients confined to bed; provide a full or partial bath or a shower, including perineal care and oral, foot, nail, and hair care; give a back rub; change a patient's gown or pajamas; change the bed linens; and straighten a patient's bedside unit and room. This is often referred to as "complete AM care." - Afternoon Care: Hospitalized patients often undergo many exhausting diagnostic tests or procedures in the morning. In rehabilitation centers patients participate in physical therapy in the morning. Afternoon hygiene care includes washing the hands and face, helping with oral care, offering a bedpan or urinal, and straightening bed linen. - Evening or Hour-Before Sleep Care: Before bedtime offer personal hygiene care that helps patients relax and promotes sleep. "PM care" often includes changing soiled bed linens, gowns, or pajamas; helping patients wash the face and hands; providing oral hygiene; giving a back massage; and offering the bedpan or urinal to nonambulatory patients. Some patients enjoy a beverage such as juice; check diet to determine which beverages are allowed.

Types of Thermometer

- Electronic - Chemical disposable - Temperature-sensitive tape - Tympanic - Temporal artery

Nursing Interventions for Clients with Indwelling Catheters

- Encourage large amounts of fluid intake - Intake of foods that create acidic urine - Perineal care - Change catheter and drainage system only when necessary - Catheterize only when necessary - Maintain sterile closed-drainage system - Remove catheter as soon as possible - Follow good hand hygiene - Prevent fecal contamination

Ongoing Assessments of Clients with Indwelling Catheters

- Ensure tubing free of obstructions - Ensure tubing not clogged - Ensure there is no tension on catheter or tubing - Ensure gravity drainage maintained - Ensure no loops in tubing below entry - Keep drainage receptacle below level of client's bladder - Ensure closed drainage system - Observe flow of urine q. 2 to 3 hours - Note color, odor, abnormal constituents - If sediment present, check more frequently

Acute care

- Enteral replacement of fluids - Restriction of fluids - have to measure what they take in - Parenteral replacement of fluids and electrolytes: * TPN - parenteral nutrition * Crystalloids (electrolytes) * Colloids

Acute Care:

- Environment - Cathartics and laxatives * Cathartics have a stronger and more rapid effect on the intestines than laxatives * Suppositories may act more quickly than oral medications - Antidiarrheal agents * Opiates used with caution - Enemas * Cleansing enemas: Tap water, Normal saline, Hypertonic solutions, Soapsuds - Oil retention * Others types of enemas: Carminative and Kayexalate - Digital Stool Removal - Inserting and Maintaining a Nasogastric Tube

Organs of Concern for Hygiene Care: The Nails

- Epithelial tissues that grow from the root of the nail bed. - Nail care (fingernails/toe nails)

Patient Hygiene Needs: Evaluation

- Evaluate outcomes NOT interventions (met, partially met, not met) - Evaluate nursing goals (met, partially met, not met) - Revise plan of care as necessary

Implementation and Evaluation: Falls:

- Events in which an individual unintentionally and through the force of gravity drops to the ground, floor, or some other lower level. - Some interventions include: * Keeping a call light within patient's reach * Keeping frequently used items close to the patient * Making hourly rounds to check on patients * Keeping patients who are at a high risk for falling in rooms close to the nurse's station * Ensure that brakes are applied on beds. * Ensure that safety locks are used on wheelchairs. * Grab bars near a toilet. * Grab bars in a shower stall.

Factors Influencing Character of Respirations

- Exercise - Anxiety - Body position - Neurological injury - Acute pain - Smoking - Medications - Hemoglobin function

Hypertension:

- Exercise reduces systolic and diastolic blood pressure readings. - Research shows that low- to moderate-intensity aerobic exercise (brisk walking or bicycling) is the most effective in lowering blood pressure. - In addition, a tai chi exercise program has demonstrated a significant reduction in systolic and diastolic blood pressures

Practice Guidelines: Facilitating Fluid Intake

- Explain reason for required intake and amount needed - Establish 24 hour plan for ingesting fluids - Set short term goals - Identify fluids client likes and use those - Help clients select foods that become liquid at room temperature - Supply cups, glasses, straws - Serve fluids at proper temperature - Encourage participation in recording intake - Be alert to cultural implications - Explain reason and amount of restriction - Help client establish ingestion schedule - Identify preferences - Set short term goals; place fluids in small containers - Offer ice chips and mouth care - Teach avoidance of ingesting chewy, salty, sweet foods or fluids - Encourage participation in recording intake

Signs and Symptoms of Transfusion Reaction

- Fever - Chills - Headache - Nausea - Back pain - Itching - Hypotension - Rash

Safety Guidelines for Urinary Elimination

- Follow principles of surgical and medical asepsis as indicated when performing catheterizations, handling urine specimens, or helping patients with their toileting needs. - Identify patients at risk for latex allergy (i.e., patients with history of hay fever; asthma; and allergies to certain foods such as bananas, grapes, apricots, kiwi fruit, and hazelnuts). - Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

Stages of the Adult Sleep Cycle

- Four stages of NREM - Sleep cycle lasts 90 to 100 minutes - Sleep goes through stages 1 to 4, then reversal from 4 to 3 to 2, followed by REM - The normal sleep pattern for an adult begins with a presleep period during which the person is aware only of a gradually developing sleepiness. This period normally lasts 10 to 30 minutes; however, if a person has difficulty falling asleep, it lasts an hour or more. - Once asleep, the person usually passes through four or five complete sleep cycles per night, each consisting of four stages of nonrapid eye movement (NREM) sleep and a period of rapid eye movement (REM) sleep. A person usually reaches REM sleep about 90 minutes into the sleep cycle. Seventy-five to 80% of sleep time is spent in NREM sleep. - With each successive cycle stages 3 and 4 shorten, and the period of REM lengthens. REM sleep lasts up to 60 minutes during the last sleep cycle. Not all people progress consistently through the stages of sleep. - Sleep becomes more fragmented with aging, and a person spends more time in lighter stages.

Growth and Development Considerations for Urinary Elimination

- G & D factors will determine the patient's ability to control the act of urination across the life span. Infants, children, and the elderly experience problems with urination. - The young need to recognize the need to urinate. - The older adult need to deal with decreased functioning that comes with aging. - Early and late pregnancy urgency is a common problem.

Implementation - Dressing: Type of Dressing

- Gauze - Transparent film - Hydrocolloid - Hydrogel - Foam - Composite

Nursing Process: Planning Bowel Elimination

- Goals and outcomes * Incorporate elimination habits or routines * Reinforce routines that promote health * Consider preexisting concerns - Setting priorities * Patients often have multiple diagnoses - Teamwork and collaboration

Nursing Process: Planning

- Goals and outcomes - goals and outcomes must be measurable and given a time frame - Common goals of care applicable to patients with infection often include the following: * Preventing exposure to infectious organisms * Controlling or reducing the extent of infection * Maintaining resistance to infection * Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene) - Setting priorities * Establish priorities for each diagnosis and for related goals of care. - Teamwork and collaboration * Remember to plan care and include other disciplines as necessary.

Factors Affecting Voiding

- Growth and Development - Sociocultural - Psychosocial factors - Personal Habits - Fluid Intake - Pathological Conditions - Surgical Procedures - Medications - Diagnostic Examinations

Both types of canes use the same basic three steps:

- Have the patient keep the cane on the stronger side of the body - Have the patient place the cane forward 15 to 25cm forward, keeping body weight on both legs - He or she will move the weaker leg forward to the cane so the weaker leg and body weight are supported by the cane

NANDA Nursing Diagnosis: Urinary Elimination

- Impaired Urinary Elimination - Readiness for Enhanced Urinary Elimination - Functional Urinary Incontinence - Overflow Urinary Incontinence - Reflex Urinary Incontinence - Stress Urinary Incontinence - Urge Urinary Incontinence

Assessment of safety for patients:

- Health history and physical assessment should dictate specific safety questions about: * Safety in the home * Poisoning * Fire and electrical hazards * Biohazards * Home temperature safety * Tripping and falling hazards * Outside environment * Work - Johns Hopkins Hospital Fall Assessment Tool * Seven-item tool, used nationally and internationally in hospitals, can be completed quickly and easily, includes fall prevention intervention guidelines - Morse Fall Scale * Six-item fall risk assessment tool, widely used nationally and internationally since the late 1980s in acute care and long-term care settings - Hendrich II Fall Risk Model * Eight-factor assessment model, well established and used widely in acute care settings to assess the fall risk of patients

Implementation in terms of medication administration

- Health promotion - Patient and Family teaching - Acute Care setting - Restorative Care - Special Considerations for - Specific Age-Groups - Infants and Children - Older Adults

Define Heat Exhaustion

- Heat exhaustion is less serious than heatstroke. Anyone who suspects that they have heat exhaustion should immediately rest and rehydrate. If symptoms do not improve, seek medical attention to prevent heatstroke. - Dehydration, loss of electrolytes

Body temperature is the

- Heat produced - Heat loss

Define Heatstroke

- Heatstroke, also called sunstroke, is the most serious heat-related illness. It occurs when the body's temperature is 104ºF or higher, and it is a life-threatening medical emergency. - If not treated immediately, heatstroke can damage multiple organs and systems, including the: Brain and nervous system Circulatory system Lungs Liver Kidneys Digestive tract Muscles

Identify the benefits of exercise with nursing interventions for the following: Musculoskeletal system

- Help maintain the musculoskeletal system during acute care by encouraging the use of stretching and isometric exercises. - During isometrics, a patient tightens or contracts a muscle group for 10 seconds and then completely relaxes for several seconds. - Repetitions are increased gradually for each muscle group until the isometric exercise is repeated 8 to 10 times. - Instruct patients to perform the exercises slowly and increase repetitions as their physical condition improves. - A patient needs to do isometric exercise for quadriceps and gluteal muscle groups, which are used for walking, 4 times per day until a patient is ambulatory.

Complications of wound healing:

- Hemorrhage: hematoma - Infection - Dehiscence: surgical complication in which a wound ruptures along a surgical incision. - Evisceration: the removal of viscera (internal organs, especially those in the abdominal cavity)

How to use Canes

- Hold cane with hand on stronger side of body - Place cane forward 6-10 inches - Move the weaker leg to the cane so that the body weight is divided between the cane and the stronger leg - Advance the stronger leg past the cane so that the weaker leg and the body weight are supported by the cane and the weaker leg

Intake and Output (I & O):

- I & O evaluates bladder emptying, renal function, and fluid and electrolyte balance. - Intake measurements: oral fluids, semi-liquids, enteral feedings, and parenteral fluids. - Output measurement: urine, vomit, gastric drainage tubes, and wound drains. - Urinary output: indicator of kidney and bladder function. - A change in urine volume can be indicator of fluid imbalance, kidney dysfunction, or decreased blood volume. - Urine output: Less than 30 mL/hr for 2 hours or excessive urine output (polyuria) report to health care provider. - Urinary output is an indirect measure of blood volume. - Urine volume is measured in receptacles with volume measurement markings: catheter drainage bag, bedside commode, bedpan, urinal, urine hat. - Pour urine into receptacle to measure.

Infiltration or extravasation

- IV fluid entering subcutaneous tissue around venipuncture site - Extravasation: technical term used when a vesicant (tissue-damaging) drug (e.g., chemotherapy) enters tissues Assessment Findings: Skin around catheter site taut, blanched, cool to touch, edematous; may be painful as infiltration or extravasation increases; infusion may slow or stop Nursing Intervention: - Stop infusion. - Discontinue IV infusion if no vesicant drug. - If vesicant drug, disconnect IV tubing and aspirate drug from catheter. Agency policy and procedures may require delivery of antidote through catheter before removal. - Elevate extremity. - Contact health care provider if solution contained KCl, a vasoconstrictor, or other potential vesicant. - Apply warm, moist or cold compress according to procedure for type of solution infiltrated. - Start new IV line in other extremity.

Gravity Drip

- IV infusion without a pump, using gravity - Must take mL per hour ordered rate and transfer to gtts per minute - Use non-pump tubing. Check packaging carefully for gtts per mL

IV Therapy

- IV therapy: crystalloids - Types of solutions * Isotonic * Hypotonic * Hypertonic - Caution: Too rapid or excessive infusion of any IV fluid has the potential to cause serious problems - Vascular access devices *Need to make sure your flow rate is correct because you can cause serious problems like fluid overload, need to keep an eye on the IV

Risk Factors for Skin Impairment:

- Immobilization - Reduced Sensation - Nutrition & Hydration Alterations - Secretions & Excretions of the Skin - Vascular Insufficiency - External Devices - Altered Cognition

Bowel Elimination Route:

- Mouth - Esophagus - Stomach - Small intestine - Large intestine - Anus - Defecation

GI system changes with exercise:

- Improves the appetite - Increases GI tract tone - Facilitates peristalsis

Describe and demonstrate the following positioning techniques. Why is position used: Supported Fowler's position

- In the supported Fowler's position the head of the bed is elevated 45 to 60 degrees, and the patient's knees are slightly elevated without pressure to restrict circulation in the lower legs. - The patient's illness and overall condition influence the angle of head and knee elevation and the length of time that the patient needs to remain in the supported Fowler's position. - Supports need to permit flexion of the hips and knees and proper alignment of the normal curves in the cervical, thoracic, and lumbar vertebrae.

Evaluation in terms of medication administration

- Include patient and family in evaluation process - Use teach-back method - Patient Outcomes

Cardiovascular changes with exercise:

- Increases HR, strength of contraction, and blood supply to the heart and muscles - Mediates harmful effects of stress • Increased cardiac output • Improved myocardial contraction, thereby strengthening cardiac muscle • Decreased resting heart rate • Improved venous return

Measuring Apical Pulse

- Indicated for those whose peripheral pulse is irregular or unavailable. Apical pulse count x 1 minute. - Primarily used prior to administering medications that affect heart rate - Also used for newborns, infants, and children up to 2-3 years old

Factors that affect sensory function: Age

- Infants and children are at risk for visual and hearing impairment because of a number of genetic, prenatal, and postnatal conditions. - Visual changes during adulthood include presbyopia and the need for glasses for reading. These changes usually occur from ages 40 to 50. - Hearing changes begin at the age of 30. Changes associated with aging include decreased hearing acuity, speech intelligibility, and pitch discrimination. - Gustatory and olfactory changes begin around age 50 and include a decrease in the number of taste buds and sensory cells in the nasal lining. Reduced taste discrimination and sensitivity to odors are common. - Proprioceptive changes common after age 60 include increased difficulty with balance, spatial orientation, and coordination. - There are also tactile changes, including declining sensitivity to pain, pressure, and temperature secondary to peripheral vascular disease and neuropathies.

Administering Blood

- Infuse within 4 hours - Use # 18 or # 20 gauge needle - because of the viscosity of blood, plus you do not want to damage RBC - Y - Set ( contains a filter) - the other goes with normal saline - Normal Saline Only - Need to make sure we have signed consent, and form is signed by two nurses to verify (any discrepancy means you send blood back to blood bank). - Need to have baseline vital signs. - Need to know allergies. - Blood product cannot hang more than 4 hours (ideally it will take about 2 hours). - When you first start, you need to stay with patient for the first 15 minutes, because if they are going to have a reaction it will be then, if they complain of pain, any change in vitals you need to stop it immediately.

IV Bolus/IV Push

- Inject medication into a port on the tubing - Many medications diluted BEFORE giving (See Med Book) - Given slowly (See Med Book) - Very dangerous route, be PRECISE

Nasal Medications

- Instilled to shrink swollen mucus membranes - Loosens secretions and facilitate drainage - Treat infections of the nasal cavity and sinuses - Suggested client blows nose first - Seated position with head tilt back - Client holds the tip of the container just inside the nares - Inhales as the spray enters the nasal passage

Administering Ophthalmic Instillations

- Instilling an eyedrop into the lower conjunctival sac - Instilling an eye ointment into the lower conjunctival sac - Pressing on the nasolacrimal duct (Want them to apply pressure for 20-30 seconds so it stays in the eye).

Safety Guidelines For Nursing Skills: Bowel Elimination

- Instruct patients who self-administer enemas to use the side-lying position. - If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate.

Types of IV Solutions

- Isotonic - Hypertonic - Hypotonic

Three Categories of Exercise:

- Isotonic Exercise - Isometric Exercise - Resistive Isometric Exercise

Controlled Substances

- Kept under lock - Special inventory forms - Documentation requirements - Counts of controlled substances - Procedures for discarding

Your body is always working to maintain equilibrium through the following Regulating mechanisms:

- Kidneys (Adrenal glands) - Lungs - Skin - Pituitary Gland (produces hormones, i.e. ADH to regulate fluids) *If any of these regulating systems are interrupted, part of the treatment will require IV electrolyte therapy with the different types of IV solutions.

What are the major structures of the urinary system?

- Kidneys = Remove waste from the blood to form urine - Ureters = Transport urine from the kidneys to the bladder - Bladder = Reservoir for urine until the urge to urinate develops - Urethra = Urine travels from the bladder and exits through the urethral meatus.

General Information on Walker

- Lightweight moveable device that stands waist high and consists of a metal frame with handgrips, four sturdy legs, and one open side - The walker provides the greatest stability and security during walking (Wide base of support) - Walkers with wheels are useful for patients that have difficulty lifting the walker while walking - The top of the walker should line up with the crease on the inside of the wrist

Applying Physical Restraints: Purpose

- Physical restraints can be applied only with a physician or health care provider order and only after all reasonable alternatives to restraint use have failed. - Physical restraints can be applied for either or both of two reasons: * Medical necessity * Behavioral or mental health issues

Preventing Urinary Tract Infections

- Maintain adequate fluid intake: 0.5 ounces/lb/day. Example: 150 lbs x 0.5 ounces = 75 ounces x 30 mL = 2,250 mL/day. Note 30 mL = 1 ounce. - Practice frequent voiding (every 2 to 4 hours) - Avoid use of harsh soaps, bubble bath, powder, or sprays in the perineal area - Avoid tight-fitting clothing - Wear cotton rather than nylon underclothes - Always wipe the perineal area from front to back following urination or defecation (girls and women) - Take showers rather than baths if recurrent urinary infections are a problem

Purpose of IV Therapy

- Maintain fluid and electrolyte balance - To administer medications - Transfuse blood and blood products - To provide parenteral nutrition

Planning Goals and Outcomes: Urinary Elimination

- Maintain or restore a normal voiding pattern - Regain normal urine output - Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem - Perform toilet activities independently with or without assistive devices - Contain urine with the appropriate device, catheter, ostomy appliance, or absorbent product

Musculoskeletal System: Excercise

- Maintain size, shape, tone, and strength of muscles (including the heart muscle) - Nourish joints - Increase joint flexibility, stability, and ROM - Maintain bone density and strength • Improved muscle tone • Increased joint mobility • Improved muscle tolerance to physical exercise • Possible increase in muscle mass • Reduced bone loss

Initiating IV Therapy

- Maintaining the system * Keeping system sterile and intact - Venipuncture - Regulating the infusion flow rate - Electronic Infusion devices (EIDs)

Tips for Easier IV starts

- Make sure patient is comfortable - Dangle arm to encourage dependent vein filling - Use warm compress - encourages vasodilation - Hands should be last choice - Limit attempt to 2 tries. - Display confidence in your own abilities

Other safety risks in health care agencies include:

- Medication errors - Radiation exposure * Excessive radiation exposure can cause injury to many body systems, including the gastrointestinal tract, skin, and reproductive organs. - Resistant microorganisms - Procedural errors

Factors Influencing Mobility-Immobility

- Mobility - Immobility - Bed rest - Muscular Deconditioning

Nursing Interventions for Fever

- Monitor vital signs - Assess skin color and temperature - Obtain blood cultures (if ordered) - Monitor laboratory results for signs of dehydration or infection - Remove excess blankets when client feels warm - Provide adequate nutrition and fluid - Measure intake and output - Reduce physical activity Administer antipyretic as ordered - i.e. ibuprofen - Provide oral hygiene - Provide dry clothing and bed linens

Adverse effect

- More severe side effect - May justify the discontinuation of a drug

Metabolism

- Most biotransformation occurs in the Liver - Other: kidneys, blood, and intestines

Collaboration and delegation for applying physical restraints

- Most facilities require restraints to be applied by a registered nurse or licensed practical nurse. - Assistance with applying and monitoring a physical restraint may be delegated to unlicensed assistive personnel (UAP) after the initial assessment of the patient.

Physical assessment of abdomen

- Mouth: Inspect the patient's teeth, tongue, and gums. Poor dentition or poorly fitting dentures influence the ability to chew. Sores in the mouth make eating not only difficult but also painful. - Abdomen: Inspect all four abdominal quadrants for contour, shape, symmetry, and skin color. Note masses, peristaltic waves, scars, venous patterns, stomas, and lesions. Normally you do not see peristaltic waves. Observable peristalsis is often a sign of intestinal obstruction. A distended abdomen feels tight like a drum; the skin is taut and appears stretched. * Normal bowel sounds occur every 5 to 15 seconds and last a second to several seconds. Absent (no auscultated bowel sounds) or hypoactive sounds occur with an ileus such as after abdominal surgery but may also mean that you did not capture the bowel sounds when you were assessing them. * High-pitched and hyperactive bowel sounds occur with small intestine obstruction and inflammatory disorders. * Percussion identifies underlying abdominal structures and detects lesions, fluid, or gas within the abdomen. Gas or flatulence creates a tympanic note. Masses, tumors, and fluid are dull to percussion. - Rectum: Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoids. Pain results when hemorrhoid tissues are irritated. * If the patient becomes constipated, passage of hard stools causes bleeding and irritation. An ice pack or a warm sitz bath provides temporary relief of swollen hemorrhoids.

Intramuscular injections:

- Needle size: 5/8 - 1 ½ inches long, 18 to 25 gauge (usually 20-25 gauge or for oil-based 18-21 guage) - Volume 1 to 3 mL - Deltoid used for small volume of medication -2 mL or less. - Ventrogluetal, vastus lateralis recommended volume - greater than 2 mL. - 90-degree angle - Always aspirate...before administering medication. *EXCEPTION: Do not aspirate when administering immunizations.

Evaluation: Urinary Elimination

- Nurse collects data to evaluate the effectiveness of nursing activities - If desired outcomes not achieved, explore the reasons before modifying the care plan

Nursing Process and Respiratory Vital Signs:

- Nursing diagnosis - history; obtain subjective and objective information: * Activity intolerance * Ineffective airway clearance * Anxiety * Ineffective breathing pattern * Impared gas exchange * Acute pain * Ineffective peripheral tissue perfusion * Dysfunctional ventilatory weaning response - Planning, interventions, evaluation

During Transfusion

- Observe patient frequently for any adverse reactions - Observe site frequent for signs of infiltration - Administer at prescribed rate (No longer than 4 hrs) - Monitor vital signs and document as per facility policy usually: * Within 1 hour before starting infusion * 15 minutes after starting infusion * Every 30-60 minutes * Whenever patients condition requires * At completion of transfusion

Risk Factors for Hygiene Problems:

- Oral - Skin - Foot - Eyes

Routes of Medication Administration

- Oral - Sublingual - Buccal - Rectal - Vaginal - Topical - Transdermal - Parenteral - Inhalation

Describe and demonstrate the following positioning techniques. Why is position used: Supine position

- Patients in the supine position rest on their backs. - In the supine position the relationship of body parts is essentially the same as in good standing alignment, except that the body is in the horizontal plane. - Use pillows, trochanter rolls, and hand rolls or arm splints to increase comfort and reduce injury to the skin or musculoskeletal system. - The mattress needs to be firm enough to support the cervical, thoracic, and lumbar vertebrae. - Shoulders are supported, and the elbows are slightly flexed to control shoulder rotation. - A foot support prevents footdrop and maintains proper alignment.

Describe and demonstrate how to assist a patient to walk.

- Patients require different interventions. You should assess the patient to determine what the proper assistance is for them. - Assess patient safety and activity tolerance. (e.g. patient fall risk or environmental conditions) - Utilize assistive devices such as quad cane, gait belt, or crutches. - Provide patient teaching to ensure the patient knows how to properly utilize assistive walking devices. - Ensure the patient has nonskid shoes on for patient safety. - Make sure walking paths are clear. Measure how far they're walking. If walking in hallway, make sure the patient has a spot to rest or sit on. - If you're assisting a patient to walk using a gait belt and you don't think you're strong enough to ambulate the patient yourself. Get another nurse to help the patient on the other side.

Describe how the nurse would assist a patient with hemiplegia and hemiparesis to walk.

- Patients with hemiplegia (one-sided paralysis) or hemiparesis (one-sided weakness) often need assistance with walking. - When an assistive device is used, stand on the patient's affected side and support him or her with a gait belt. * Providing support by holding the patient's arm is incorrect because the nurse cannot easily support the patient's weight to lower him or her to the floor if he or she faints or falls. In addition, if the patient falls with the nurse holding an arm, a shoulder joint may be dislocated.

Pulse Rhythm

- Pattern of beats and intervals between beats - Dysrhythmia: regularly or irregularly/irregular *If you have a regular rhythm you count for 30 seconds and multiply by 2 **If irregular have to count for 1 minute (using apical rate)

Physical Assessment in Urinary Elimination

- Percussion of kidneys and bladder to detect tenderness - Inspect urethral meatus for swelling, discharge, inflammation - Skin color, texture, turgor, signs of irritation - Edema

Specific home and community safety concerns include:

- Poisoning: - Toxins: - Lead poisoning: - Carbon monoxide:

Safety Guidelines for Nursing Skills

- Position patient to prevent the patient from rolling over the side of the bed. - Keep a plastic bag within reach to discard dressings and prevent cross-contamination. Keep extra gloves within reach to allow a change of gloves if the gloves become soiled. - If irrigating a wound, use appropriate PPE. - When applying an elastic bandage, check the extremity for temperature or sensation changes.

Pathological Influences on Mobility:

- Postural abnormalities - Impaired muscle development - Damage to CNS - Musculoskeletal trauma

Oral Supplements

- Potassium - if you take a diuretic you might waste potassium - Calcium - Multivitamins - Sports drink

Pharmacist's Role

- Prepares and distributes medications - Responsible for dispensing the correct medication.

Implementation: Bandages and binders

- Principles for applying bandages and binders - Binder application: slings - Bandage application

IV "Head to Toe" Assessment

- Proceed from IV bag to the IV site - Bag: Clear? Particles Correct/expired IVF? - Pump/Gravity Drip: Set correctly? - Tubing: Kinks? Air? Precipitate? Tangled? Catheter secure at site? Piggyback secure? - IV Site: c/o swelling? redness? pain? tenderness? patent? catheter size? infusing or to HL/SL? leaking? (look for infiltration) - Document

IV Pumps

- Program the pump in mL per hour - mL's are usually in whole numbers - Learn to "troubleshoot" the pump, pump will "beep" to signal a problem - Most pediatric clients receive meds via pumps - Strong medications often are given via pump

Importance of sleep:

- Proper rest and sleep are as important to health as good nutrition and adequate exercise. - Physical and emotional health depends on the ability to fulfill these basic human needs. - Individuals need different amounts of sleep and rest. - Without proper amounts, the ability to concentrate, make judgments, and participate in daily activities decreases; and irritability increases. - Identifying and treating patients' sleep pattern disturbances are important goals. To help patients you need to understand the nature of sleep, the factors influencing it, and patients' sleep habits. - Sleep provides healing and restoration. - Some patients have preexisting sleep disturbances; other patients develop sleep problems as a result of an illness or hospitalization.

Physiology and Regulation of Movement: Skeletal System

- Provides attachments for muscles and ligaments and protects vital organs - Provides leverage for movement - Bones are long, short, flat, or irregular. - Protects vital organs - Aids in calcium regulation

Inserting and Maintaining a Nasogastric Tube

- Purposes: A patient's condition or situation sometimes requires special interventions to decompress the GI tract. Such conditions include surgery, obstruction of the GI tract often caused by tumors, trauma to the GI tract, and conditions in which peristalsis is absent. A nasogastric (NG) tube is a pliable hollow tube that is inserted through the patient's nasopharynx into the stomach. NG intubation has several purposes: * Decompression, enteral feeding, compression, and lavage - Categories of nasogastric (NG) tubes * Fine- or small-bore for medication administration and enteral feedings * Large-bore (12-French and above) for gastric decompression or removal of gastric secretions - Clean technique - Maintaining patency

Delegation of pulse measurement:

- Radial or brachial pulse may be delegated to UAP - Nurse interprets abnormal rates or rhythms and determines response - UAP are generally not responsible for assessing apical or one person apical-radial pulses

Fluid Balance - Assessment: Medical History

- Recent surgery (physiological stress - cortisol levels are up) - Gastrointestinal output - diarrhea, vomiting - Acute illness or trauma: * Respiratory disorders - COPD * Burns - more burn, greater fluid loss * Trauma - Chronic illness: * Cancer * Heart failure - decreased cardiac out put * Oliguric renal disease

Z - track method

- Recommended when giving intramuscular injection. - Prevents medication from leaking back into subcutaneous tissue.

Integumentary System and immobility:

- Reduced skin turgor - Skin breakdown - Risk factors for pressure ulcers = turn patient - Skin tear will be difficult to heal considering metabolic deficiencies. - Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Purpose of sleep

- Remains unclear - Physiological and psychological restoration - Maintenance of biological functions - NREM sleep contributes to body tissue restoration. - During sleep the heart rate falls to 60 beats/min or less, which benefits cardiac function. Other biological functions decreased during sleep are respirations, blood pressure, and muscle tone. - The body needs sleep to routinely restore biological processes. During deep slow-wave (NREM stage 4) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for renewal of tissues such as the skin, bone marrow, gastric mucosa, or brain occur during rest and sleep. NREM sleep is especially important in children, who experience more stage 4 sleep. - Another theory about the purpose of sleep is that the body conserves energy during sleep. - The skeletal muscles relax progressively, and the absence of muscular contraction preserves chemical energy for cellular processes. Lowering of the basal metabolic rate further conserves body energy supply. - REM sleep is necessary for brain tissue restoration and appears to be important for cognitive restoration and memory. - A loss of REM sleep leads to feelings of confusion and suspicion.

Evidence-based practice: Applying physical restraints

- Restraint use has caused negative health outcomes, such as deterioration in the ability to walk, in cognitive abilities, and in performing activities of daily living. - Waist restraints or lap restraints are as harmful and restrictive as vest restraints, and they have just as many adverse events attributed them. All other alternatives must be implemented before initiating any type of restraint. - Proper training and education of staff can reduce the use of restraints. Education includes understanding alternative options, de-escalation techniques, regulatory standards, barriers to change and overcoming resistance, and issues of violence, aggression, and power. - Ethical considerations do not preclude the use of restraints, but alternatives should be implemented before restraint initiation to avoid further physical, mental, ethical, and social harm. - During application of a restraint, the primary nurse should be calm and reassure the patient that it is not a punishment. Focus must remain on the emotional and social health of the patient, or the situation may escalate for the patient and staff.

Delegation of body temperature:

- Routine measurement may be delegated to UAP - UAP reports abnormal temperatures - Nurse interprets abnormal temperature and determines response

What are SCDs and elastic stockings?

- SCDs and intermittent pneumatic compression (IPC) are used to prevent blood clots in the lower extremities. These consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and secured with Velcro. Once they are applied, connect the sleeves to a pump that alternately inflates and deflates the stocking around the leg. A typical cycle is inflation for 10 to 15 seconds and deflation for 45 to 60 seconds. Inflation pressures average 40 mm Hg. Use of SCD/IPC on the legs decreases venous stasis by increasing venous return through the deep veins of the legs. For optimal results begin use of SCD/IPC as soon as possible and maintain it until the patient becomes fully ambulatory. - Elastic stockings (sometimes called antiembolitic stockings) also aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return

Safety interventions for other areas of concern in the health care environment include:

- Safe medication administration practices - Reduction of pathogen transmission - Reduction of procedure- and equipment-related events - Successful management of bioterrorist attack

Nursing Process: Evaluation

- See through the patient's eyes: * Have the patient's expectations been met? - Patient outcomes * Measure the success of the infection control techniques. * Compare the patient's actual response with expected outcomes. * If goals are not achieved, determine what steps must be taken. - Exposure issues

Patient Hygiene Needs: Diagnosis

- Self-care Deficit: bathing/hygiene/oral - Low Esteem - Knowledge Deficit: Hygiene Practices - Fatigue - Impaired Physical Mobility - Ineffective Health Maintenance - Risk For Impaired: skin Integrity - Risk For Infection

How does sensory deprivation occur?

- Sensory stimulation must be of sufficient quality and quantity to maintain a person's awareness. - Three types of sensory deprivation are: * Reduced sensory input (sensory deficit from visual or hearing loss) * The elimination of patterns or meaning from input (e.g., exposure to strange environments) * Restrictive environments (e.g., bed rest) that produce monotony and boredom **There are many effects of sensory deprivation. In adults the symptoms are similar to those of psychological illness, confusion, symptoms of severe electrolyte imbalance, or the influence of psychotropic drugs. Therefore always be aware of a patient's existing sensory function and the quality of stimuli within the environment.

Patient safety

- Separate personal care items - Handling exudate - Wound cleaning - clean outward from wound bed - Cough etiquette - don't cough in hands, wash hands - Dirty linen - hold away from your body - Maintain skin integrity - make sure moisturized, sheets to move patients to protect against friction. - Perineal care after toileting - wipe front to back - Urinary catheters and drainage sets - Wound cleaning

Hair Care:

- Shampoo - Combing & Brushing - Shaving - Beard & Mustache

Inflammation

- Signs of local inflammation and infection are identical. - Vascular and cellular responses - Exudates (serous, sanguineous, or purulent) - Tissue repair *When you have a wound, you can have exudate (serous is the clear kind of like plasma, sanguineous contains RBCs, and purulent contains WBCs and bacteria (pus))

Describe and demonstrate the following positioning techniques. Why is position used: Sims'

- Sims' position differs from the side-lying position in the distribution of the patient's weight. - In Sims' position the patient places the weight on the anterior ileum, humerus, and clavicle.

Implementation: Health Promotion: Promotion of Normal Defecation

- Sitting Position: Help patients who have difficulty sitting because of muscular weakness and mobility problems. Place an elevated seat on the toilet or a bedside commode when patients are unable to lower themselves to a sitting position because of pain or weakness. - Privacy - Positioning on bedpan: When positioning a patient, it is important to prevent muscle strain and discomfort. Never try to lift a patient onto a bedpan. The proper position for the patient on a bedpan is with the head of the bed elevated 30 to 45 degrees. Wear gloves when handling bedpans. When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan. *Can be delegated to NAP

Things involved in the regulation of movement?

- Skeletal system - Joints - Ligaments, tendons, cartilage - Skeletal muscle - Muscles concerned with movement - Muscles concerned with posture - Muscle groups - Nervous system - Proprioception - Balance

UAP should report any of the following to the nurse after checking restraints:

- Skin changes (e.g., sores, wounds, irritations, lesions) in the area where the restraint is to be applied - Patient complaints related to restraint application, especially tightness, numbness, tingling, or pain - Changes in basic assessments that can be delegated to UAP, such as changes in vital signs - Patient communications of an unusual nature and any unusual concerns

Sleep: Assessment

- Sleep assessment: sources for sleep assessment = Patient, family. Tools for sleep assessment - Sleep history: description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation - Ask about usual sleeping pattern - Ask about history of sleep disturbances and delve deeper - Inquire about any physical or mental illnessess, as sleep disturbances could stem from that.

Physiology of Sleep: Sleep Regulation

- Sleep is associated with changes in the peripheral nervous, endocrine, cardiovascular, respiratory, and muscular systems. - Specific physiological responses and patterns of brain activity identify each sequence. - Instruments such as the electroencephalogram (EEG), which measures electrical activity in the cerebral cortex; the electromyogram (EMG), which measures muscle tone; and the electrooculogram (EOG), which measures eye movements provide information about some structural physiological aspects of sleep. - The major sleep center in the body is the hypothalamus. It secretes hypocreatins (orexins) that promote wakefulness and rapid eye movement sleep. Prostaglandin D2, L-tryptophan, and growth factors control sleep. - Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness. The RAS receives visual, auditory, pain, and tactile sensory stimuli. Activity from the cerebral cortex (e.g., emotions or thought processes) also stimulates the RAS. Arousal, wakefulness, and maintenance of consciousness result from neurons in the RAS releasing catecholamines such as norepinephrine. The homeostatic process (Process S), which primarily regulates the length and depth of sleep; and the circadian rhythms (Process C: "biological time clocks"), which influence the internal organization of sleep, timing and duration of sleep-wake cycles, operate simultaneously to regulate sleep and wakefulness. - Time of wake up is defined by the intersection of Process S and Process C.

Factors Influencing Hygienic Practices

- Social Practices - Personal - Socioeconomic Status - Body Image - Physical Mobility (Limb Dexterity) - Health Benefits & Motivation - Cultural Variables

COPD:

- Some patients are fearful of participating in exercise because of the potential of worsening dyspnea (difficulty breathing). This aversion to physical activity sets up a progressive deconditioning in which minimal physical exertion results in dyspnea. - Pulmonary rehabilitation provides a safe environment for monitoring patients' progress. - In addition, they receive encouragement and support to increase activity and exercise

Implementation: Suture care

- Staple Removal - Suture removal

Indwelling Catheter

- Sterile Procedure - Educate patient that it is a sterile procedure and that they are to remain still and not move during the procedure. - Tell patient what to expect prior to, during, after procedure. - As you proceed talk to your patient and let them know what is happening next.

Purpose of sterile gloving:

- Sterile gloving technique protects highly susceptible patients, open wounds, and sterile objects from the transfer of microorganisms. - Sterile gloving technique is required in procedures requiring sterile technique, for example such as insertion of foley catheter.

Enema administration

- Sterile technique is unnecessary. - Wear gloves. - Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation. - Make sure they are on a bedpan and not a toilet (unsafe because position f the rectal tubing could injure the rectal wall

Surgical Asepsis

- Sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery - Includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area - Situations surgical asepsis is used - Patient preparation - Sterile field: an area free of microorganisms and prepared to receive sterile items - Performing sterile procedures: - Donning and removing caps, masks, and eyewear - Opening sterile packages - Opening a sterile item on a flat surface - Opening a sterile item while holding it - Preparing a sterile field - Pouring sterile solutions - Surgical scrub - Applying sterile gloves - Donning a sterile gown

Administering Otic Instillations

- Straightening the adult ear canal by pulling the pinna upward and backward - Instilling eardrops.

Health Promotion and Vital Signs

- Teach how to monitor vital signs in home setting. - Include patient/family/caregiver - Use the teach-back method

What are the different pulse sites?

- Temporal - Carotid - Brachial - Radial - Apical - Femoral - Popliteal - Posterior Tibial - Dorsalis Pedis

Bowel Diversions

- Temporary or permanent artificial opening in the abdominal wall * Stoma - Surgical opening in the ileum or colon * Ileostomy or colostomy - Ostomies * Sigmoid colostomy * Transverse colostomy * Ileostomy * Loop colostomy * End colostomy

Patient Hygiene Needs: Assessment

- The Assessment Interview - Skin Assessment: (Braden or Norton Scale) - Skin problem history - Hygienic practices - Self-care ability of the patient: (Functional Status & Assessment tools)

Factors that affect sensory function: Social interaction

- The amount and quality of social contact with supportive family members and significant others influence sensory function. The absence of visitors during hospitalization or residency in an extended care facility influences the degree of isolation a patient feels. - Therefore the absence of meaningful conversation results in feelings of isolation, loneliness, anxiety, and depression for a patient. Often this is not apparent until behavioral changes occur.

Identify the benefits of exercise with nursing interventions for the following: Joint mobility

- The easiest intervention to maintain or improve joint mobility for patients and one that can be coordinated with other activities is the use of ROM exercises. - In active ROM exercises patients are able to move their joints independently. - With passive ROM exercises you move each joint in patients who are unable to perform these exercises themselves. - The use of ROM exercises provides data to systematically assess and improve the patient's joint mobility. - Joints that are not moved periodically are at risk for contractures, a permanent shortening of a muscle followed by the eventual shortening of associated ligaments and tendons. - Over time the joint becomes fixed in one position, and the patient loses normal use of it. - Passive ROM exercises are the exercises of choice for patients who do not have voluntary motor control. - Unless contraindicated, the nursing care plan includes exercising each joint through as nearly a full ROM as possible. - Initiate passive ROM exercises as soon as the patient loses the ability to move the extremity or joint.

Describe and demonstrate the following positioning techniques. Why is position used: Prone position

- The patient in the prone position lies face or chest down. - Often his or her head is turned to the side; but, if a pillow is under the head, it needs to be thin enough to prevent cervical flexion or extension and maintain alignment of the lumbar spine. - Placing a pillow under the lower leg permits dorsiflexion of the ankles and some knee flexion, which promote relaxation. - If a pillow is unavailable, the ankles need to be in dorsiflexion over the end of the mattress. - Although the prone position is seldom used in practice, consider this as an alternative, especially in patients who normally sleep in this position. - The prone position also may have some benefits in patients with acute respiratory distress syndrome and acute lung injury. - Specialty beds that safely position acutely ill patients in the prone position are available.

Cleaning

- The removal of all soil - Use protective eyewear and gloves - Steps 1. Rinse contaminated object or article with cold running water to remove organic material. 2. Wash the object with soap and warm water. 3. Use a brush to remove dirt or material in grooves or seams. 4. Rinse the object in warm water. 5. Dry the object and prepare it for disinfection or sterilization if indicated 6. Clean and dry cleaning equipment

Electrical impulses originate from

- The sinoatrial (SA) node. - Cardiac output, heart rate, stroke volume *Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume.

Helping Patients to Exercise: Delegation Considerations

- The skill of helping patients exercise is a self-care activity. - However, in the acute care setting it can be delegated to nursing assistive personnel (NAP). - A nurse first must assess the patient's ability and tolerance to exercise. - The nurse also teaches patients and their families how to implement exercise programs at home. - NAP can prepare patients for exercise (e.g., putting on shoes and clothing, providing hygiene needs and obtaining preexercise and post-exercise vital signs).

Describe the use of the following with rationale(s): Trapeze bar

- The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. - It allows a patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper-arm exercises. - It increases independence, maintains upper-body strength, and decreases the shearing action from sliding across or up and down in bed.

Obstructive sleep apnea (OSA)

- The two major risk factors for OSA are obesity and hypertension. - OSA occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea) for as long as 30 seconds. - Excessive daytime sleepiness is the most common complaint. - Feelings of sleepiness are usually most intense on awakening, right before going to sleep, and about 12 hours after the midsleep period. - Causes a serious decline in arterial oxygen saturation level.

Infection Control and Hygiene in Terms of Urinary Elimination

- The urinary tract is sterile. The use of infection control principles will help to control the spread of UTI. Perineal care or examination of the genitalia requires medical asepsis, including proper hand hygiene. - Invasive procedures such as catheterization requires sterile technique.

Fluid intake:

- Thirst regulates fluid intake - Intake is about 2200 to 2700 ml per day - Fluid Distribution: (movement of fluid among blood cells) - Osmosis - Filtration

Nursing Process: Evaluation Bowel Elimination

- Through the patient's eyes * The patient or caregiver determines which therapies were the most effective - Patient outcomes * Develop a therapeutic relationship * Evaluate a patient's level of knowledge * Determine the extent to which the patient accomplishes normal defecation * Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health

Nursing Process: Assessment Bowel Elimination

- Through the patient's eyes - Nursing history. 1156, Box 47-3 * What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination. * Identifying normal and abnormal patterns, habits, and the patient's perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient's problems. * Want to collect information on: signs and symptoms, onset, duration, associated symptoms, character and exposures, medical history, and effects on the patient

Nursing Process: Assessment

- Through the patient's eyes - Skin: continually assess skin for signs of breakdown and/or ulcer development - Pressure ulcer: predictive measures; mobility; nutritional status; body fluids; pain - Wounds: wound appearance; character of wound drainage; drains; wound closures; palpation of wound; wound cultures

Examples of common reasons for the use of physical restraints are as follows:

- To immobilize an extremity - To prevent harmful patient behavior - To allow treatments or procedures to proceed without patient interference

Common Urinary Elimination Problems

- Urinary retention - Urinary tract infection - Urinary incontinence

Urinary Elimination Changes with immobility:

- Urinary stasis - Renal calculi - Infection - Bed rest decreases gravities help with urine flow - Urinary stasis and indwelling catheter increases the risk for UTI and renal calculi - Further complication = dehydration - Exercise is crucial to promoting blood flow in kidneys and reduction of waste

Central Line Care

- Use sterile technique - Changed every 3-7 days, depending on site and agency policy. Dressings should be changed when loose or soiled. - Assess site for redness, swelling, tenderness, or drainage. - Measure the length of the external portion of the catheter with its documented length to assess for possible displacement. If, PICC line measure circumference of arm. - Follow agency protocol for cleaning solutions and types of dressing. - Clean site area starting at the center of the site, moving outwards with circular motion, allow site to air dry. - Cover with occlusive dressing. - Change cap as per agency protocol, usually every 3-7 days. - Flush with normal saline 10 mL, a heparin flush (10 units/mL or 100 units/mL) or as agency protocol recommends for the specific type of VAD being used. - Flush after infusing medications or solutions, again flush the VAD with normal saline before using heparin flush solution. - The frequency of flushes between uses may vary from every 12 hours to once a week or less, depending on the type of catheter. - Remember to flush all lumens for multiple lumen catheters. - Implanted venous access device (port a cath) use a Huber needle to access the port. - Flush idle implanted ports with heparinized saline according to agency protocol.

Cultural Aspects of Care

- Value of Modesty - Gender Congruence - Role of Superstitions in a Culture

Intramuscular Injections sites:

- Ventrogluteal - Vastus lateralis - Deltoid

Needle Length for Adults

- Ventrogluteal site - 1 ½ inch. - Vastus lateralis site - 5/8- to 1-inch - Deltoid - 1- to 1 ½ inch. *NOTE: Needle length corresponds to injection site, age, and size of patient.

Identify the benefits of exercise with nursing interventions for the following: Walking

- Walking increases joint mobility and can be measured by length of time or distance walked. - Measure distances walked in feet or yards instead of charting "ambulated to nurses' station and back." Illness or trauma usually reduces activity tolerance, resulting in the need for help with walking or the use of assistive devices such as crutches, canes, or walkers. - Patients who increase their walking distance before discharge improve their ability to independently perform basic ADLs, increase activity tolerance, and have a faster recovery after surgery

As the nurse what questions would you ask to assess ROM and the type of ROM exercise patient can perform.

- When assessing ROM, ask questions about and physically examine the patient for stiffness, swelling, pain, limited movement, and unequal movement. - Patients whose mobility is restricted require ROM exercises to reduce the hazards of immobility. - Limited ROM often indicates inflammation such as arthritis, fluid in the joint, altered nerve supply, or contractures. - Increased mobility (beyond normal) of a joint sometimes indicates connective tissue disorders, ligament tears, or possible joint fractures. - Assess the type of ROM exercise that a patient is able to perform. - First consider the medical plan of care and if active ROM exercises are appropriate; then assess the patient's ability to engage in active ROM exercises. - ROM exercises are active (the patient moves all joints through his or her ROM unassisted), passive (the patient is unable to move independently, and the nurse moves each joint through its ROM), or somewhere in between. - For example, you might need to provide support for a weak patient while he or she performs most of the joint movement. - Some patients are able to move some joints actively, whereas you will passively move others. - Your assessment will help to determine the patient's need for assistance, teaching, or reinforcement. - In general, exercises need to be as active as health and mobility allow. - Contractures develop in joints that are not moved periodically through their full ROM. - Assessment data from patients with limited joint movements vary on the basis of the area affected.

Guidelines for Measuring Vital Signs

- Working equipment appropriate for the size and age of the client. - Appropriately delegate measurement - Be able to understand and interpret values - Know the client's usual range of vital signs. - Determine the client's medical history, therapies, and prescribed medications. - Control or minimize environmental factors that affect vital signs. - Use an organized, systematic-approach when taking vital signs. - Know the acceptable ranges for your clients before administering medications, and use vital sign measurements to determine indications for medication administration. - Communicate findings. - Accurately document findings. - Analyze the results of vital sign measurement. - Instruct the client or caregiver in vital sign assessment and the significance of findings.

Narcolepsy

- aka cataplexy or sleep paralysis - A dysfunction of mechanisms that regulate the sleep and waking states. - During the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep; REM sleep occurs within 15 minutes of falling asleep. - Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day. - Sleep paralysis is another symptom.

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

1, 3, 5, 4, 2 1. Remove gloves. 3. Remove eyewear or goggles. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side. 4. Untie top and then bottom mask strings and remove from face. 2. Perform hand hygiene.

Place the following options in the order in which elastic stockings should be applied. 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.

1, 5, 7, 4, 6, 3, 2 1. Identify patient using two identifiers. 5. Assess the condition of the patient's skin and circulation of the legs. 7. Use tape measure to measure patient's legs to determine proper stocking size. 4. Turn the stocking inside out until heel is reached. 6. Place toes into foot of the stocking. 3. Slide the remainder of the stocking over the patient's heel and up the leg 2. Smooth any creases or wrinkles.

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake."

1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet."

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does a nurse program into the infusion pump? 1. 125 mL/hr 2. 167 mL/hr 3. 200 mL/hr 4. 1000 mL/hr

1. 125 mL/hr

The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%

A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia? 1. A 72-year-old with chronic alcoholism 2. A 79-year-old with bone cancer 3. A 41-year-old with hypernatremia 4. A 46-year-old with respiratory acidosis

1. A 72-year-old with chronic alcoholism

Which patient is most likely to experience sensory overload? 1. A patient in the intensive care unit whose pain is not well controlled 2. A patient with a protective patch on her right eye following cataract surgery 3. A woman whose hearing aids were lost when she transferred to a long-term care facility 4. A visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities

1. A patient in the intensive care unit whose pain is not well controlled

Principles of surgical asepsis:

1. A sterile object remains sterile only when touched by another sterile object 2. Only sterile objects may be placed on a sterile field 3. A sterile object or filed out of the range of vision or an object held below a person's waist is contaminated 4. A sterile object or field becomes contaminated by prolonged exposure to air 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object of field becomes contaminated by capillary action 6. Fluid flows in the direction of gravity 7. The edges of a sterile field of container are considered to be contaminated

Principles of Surgical Asepsis

1. A sterile object remains sterile only when touched by another sterile object. 2. Only sterile objects may be placed on a sterile field. 3. Sterile field or object must be seen at all times. DO NOT TURN YOUR BACK ON FIELD. 4. Sterile field or objects must be waist high. 5. Avoid prolonged exposure to air. 6. Any spill, moisture, on sterile field is considered contaminated. 7. The principle of fluid flows in direction of gravity. For example, surgical hand scrub hold your hand above your elbows. Dry from fingers to elbows. 8. One-inch border of any sterile field is considered contaminated.

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 5. Use a slow, circular steady massage.

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

1. Ask the patient about any allergies and reactions. 4. Ensure that informed consent has been obtained.

A pediatric nurse takes a medication to a 12-year-old female patient. The patient tells the nurse to take it away because she is not going to take it. What is the nurse's next action? 1. Ask the patient's reason for refusal 2. Consult with the patient's parents for advice 3. Take the medication away and chart the patient's refusal 4. Tell the patient that her health care provider knows what is best for her

1. Ask the patient's reason for refusal

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? (Select all that apply.) 1. Assess the injection site 2. Administer an oral medication for pain 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record 5. This is a normal finding so nothing needs to be done 6. Apply ice to the site for relief of burning pain

1. Assess the injection site 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record

A nurse is preparing to provide a patient with instructions for how to perform incentive spirometry. The patient will likely have incisional pain after returning from an elective colon resection. Which of the following steps for incentive spirometry is the patient likely to have the most difficulty performing? (Select all that apply.) 1. Assuming semi-Fowler's or high-Fowler's position 2. Setting the incentive spirometer device scale at the volume level to be attained 3. Placing the mouthpiece of the incentive spirometer so lips completely cover the mouthpiece 4. Inhaling slowly while maintaining constant flow through unit until it reaches goal volume 5. Breathing normally for a short period between each of the 10 breaths on incentive spirometry 6. Ending with two coughs after the end of 10 incentive spirometry breaths hourly

1. Assuming semi-Fowler's or high-Fowler's position 4. Inhaling slowly while maintaining constant flow through unit until it reaches goal volume 6. Ending with two coughs after the end of 10 incentive spirometry breaths hourly

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) 1. Avoid grapefruit and grapefruit juice, which impair drug absorption. 2. Increase the amount of carbohydrates for energy. 3. Take a multivitamin that includes vitamin D for bone health. 4. Cheese and eggs are good sources of protein. 5. Limit fluids to decrease the risk of edema.

1. Avoid grapefruit and grapefruit juice, which impair drug absorption. 3. Take a multivitamin that includes vitamin D for bone health. 4. Cheese and eggs are good sources of protein.

What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter.

1. Bladder scan the patient immediately after voiding.

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? (Select all that apply.) 1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors 5. Increased computer use

1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool

1. Bruising 3. Bleeding gums 4. Coffee ground-like vomitus

You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this health care provider does not like to be called, and you know that another of the health care provider's patients is very unstable. What is the most appropriate next step for you to take? 1. Call the health care provider to clarify the order 2. Talk with your preceptor to help you interpret the order 3. Refer to a medication manual before giving the medication 4. Use your best judgment and critical thinking and administer the dose you think the health care provider ordered

1. Call the health care provider to clarify the order

A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible

1. Calls the health care provider and questions the order

Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

1. Category/stage I a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. 2. Category/stage II d. Partial-thickness skin loss or intact blister with serosanguinous fluid. 3. Category/stage III b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. 4. Category/stage IV c. Full thickness tissue loss; muscle and bone visible. May include undermining.

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) 1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 4. Release both limbs at the same time to perform range of motion (ROM) 5. Inspect the skin under each restraint

1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 5. Inspect the skin under each restraint

The primary reason that you need to include family members when you teach a patient preoperative exercises is so they can: 1. Coach and encourage the patient after surgery. 2. Demonstrate to the patient at home. 3. Relieve the nurse by getting the patient to do the exercises every 2 hours. 4. Practice with the patient while he or she is waiting to be taken to the operating room.

1. Coach and encourage the patient after surgery.

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert

1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

1. Decreased peristalsis

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies does the nurse implement? (Select all that apply.) 1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 3. Demonstrate how to wash the earmold and microphone with hot water. 4. Discuss the importance of having wax buildup in the ear canal removed. 5. Recommend a chemical cleaner to remove difficult buildup.

1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 4. Discuss the importance of having wax buildup in the ear canal removed.

Four stages of the infectious process:

1. Incubation Period 2. Prodromal Stage 3. Illness Stage 4. Convalescence

An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.) 1. Dentures do not always fit properly. 2. Most older adults have an increase in saliva secretions. 3. With aging the periodontal membrane becomes tighter and painful. 4. Many older adults are edentulous, and remaining teeth are often decayed. 5. The teeth of elderly patients are more sensitive to hot and cold.

1. Dentures do not always fit properly. 4. Many older adults are edentulous (lacking teeth), and remaining teeth are often decayed.

Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N 95 respirator mask 3. Face shield or goggles 4. Surgical mask 5. Gloves

1. Disposable gown 2. N 95 respirator mask 5. Gloves

A patient has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 3. Encouraging increased fluid intake 4. Monitoring for constipation

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 4. Monitoring for constipation

An 86-year-old woman is admitted to the unit with chills and a fever of 104° F. What physiological process explains why she is at risk for dyspnea? 1. Fever increases metabolic demands, requiring increased oxygen need. 2. Blood glucose stores are depleted and the cells do not have energy to use oxygen. 3. Carbon dioxide production increases due to hyperventilation. 4. Carbon dioxide production decreases due to hypoventilation.

1. Fever increases metabolic demands, requiring increased oxygen need.

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 6. Applying a moisture barrier ointment

Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? (Select all that apply.) 1. Giving the patient a backrub 2. Turning on quiet music 3. Dimming the lights in the patient's room 4. Giving a patient a cup of coffee 5. Monitoring for the effect of the sleeping medication that was given

1. Giving the patient a backrub 2. Turning on quiet music 3. Dimming the lights in the patient's room

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high-school students. Which points should be included in the education? (Select all that apply.) 1. Go to bed at the same time each night. 2. Study in your bedroom to have a quiet place. 3. Turn on the television to help you fall asleep. 4. Avoid drinking coffee or soda before bedtime. 5. Turn off your cell phone at bedtime.

1. Go to bed at the same time each night. 4. Avoid drinking coffee or soda before bedtime. 5. Turn off your cell phone at bedtime.

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? 1. Have the patient perform a Valsalva maneuver 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line 3. Have the patient take a deep breath and hold it 4. Notify the health care provider immediately

1. Have the patient perform a Valsalva maneuver (is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon.)

Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine if the ostomy is healing appropriately

1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine if the ostomy is healing appropriately

Six "Rights" of Accurate Medication Administration

1. Right medication - check 3 times 2. Right dose 3. Right patient 4. Right route 5. Right time - can give 30 min prior or 30 min after scheduled time 6. Right documentation

Helping Patients to Exercise: Steps

1. Identify patient using two identifiers (e.g., name and birthday or name and medical record number according to agency policy). 2. Assess for any medical limitations (e.g., weight-bearing status, untreated fracture, partial paralysis, peripheral neuropathy of feet, current pregnancy, cardiovascular disease). 3. Know patient's mobility level before trauma, illness, or hospitalization. 4. Gather baseline assessment of vital signs and O2 saturation (if available). 5. Assess patient's pain level. Ask patient to rate pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain ever. An analgesic may be needed 30 minutes before exercise but should not have sedative properties. 6. Assess patient's beliefs, values, and perceptions regarding current health status and confidence in being capable of performing exercise. 7. Assess patient's cognitive status and ability to follow instructions while implementing exercise. 8. Assess for joint limitations and do not force a muscle or a joint during exercise. 9. Have patient wear comfortable nonskid shoes. In the home setting, encourage wearing comfortable clothes. 10. Instruct patient to take slow, deep breaths and to focus on relaxation to reduce anxiety and fully oxygenate tissues and expand lungs. 11. When exercising (e.g., ambulating or moving to a chair, walking at home), have the patient move at his or her own pace. 12. Monitor for dizziness, which is an indicator of postural hypotension. 13. Observe for proper posture, body alignment, and body mechanics during exercise. 14. Monitor vital signs before, during, and after exercise. 15. Terminate physical activity if patient's heart rate is greater than 30 beats per minute over baseline; if there is a change in patient's heart rhythm; if the patient is hypotensive (change in systolic BP of 30 mm Hg or change in diastolic BP of 10 mm Hg); if the patient develops dizziness that lasts 60 seconds, fainting, or diaphoresis; if there is a change in patient's breathing pattern with an increase in accessory muscle use; or if patient develops extreme fatigue or severe dyspnea with respiratory rate greater than baseline by more than 20 breaths/min 16. Use Teach Back to determine patient and family understanding about safe exercise activities. State, "I want to be sure I explained how to safely exercise at home or in your community to prevent the risk for exercise-related injury. Can you explain to me the proper shoes for exercise and how to gradually increase your activity?" Revise your instruction now or develop plan for revised patient teaching if patient is not able to teach back correctly. 17. Document patient's progress and provide feedback as patient exercises.

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.) 1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets 6. Staircases with handrails

1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet 2. Use a low-volume enema daily 3. Avoid gluten in the diet 4. Take laxatives twice a day 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day 7. Take probiotics 5 times a week

1. Increase fiber and fluids in the diet 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day

The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely: 1. Increase the patient's risk for falls and injuries. 2. Result in less stress on the patient's joints. 3. Decrease the amount of work required for patient movement. 4. Allow for mobility in spite of the aging effects on the patient's joints.

1. Increase the patient's risk for falls and injuries.

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails

A patient is admitted through the emergency department following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open-reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this patient include: (Select all that apply.) 1. Intermittent pneumatic compression stockings. 2. Vitamin K therapy. 3. Passive range-of-motion exercises every 4 hours. 4. Subcutaneous heparin or enoxaparin (Lovenox). 5. Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.

1. Intermittent pneumatic compression stockings. 4. Subcutaneous heparin or enoxaparin (Lovenox).

Parenteral administration involves injecting a medication into body tissues. The following are the four major sites of injection:

1. Intradermal (ID): Injection into the dermis just under the epidermis 2. Subcutaneous: Injection into tissues just below the dermis of the skin 3. Intramuscular (IM): Injection into a muscle 4. Intravenous (IV): Injection into a vein

A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: 1. It promotes venous circulation. 2. It covers a larger area of the leg. 3. It completes care in a timely fashion. 4. It prevents blood clots in legs.

1. It promotes venous circulation.

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1. Keep the bowels regular. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back.

How to use walkers: When maximum support is needed

1. Move the walker ahead - body weight is supported by both legs 2. Move the right foot up to the walker - Body weight is supported by the left leg and both arms 3. Move the left foot up to the right foot - Body weight is being supported by the right leg and both arms

How to use Walker: When One Leg is Weaker

1. Move the walker and the weaker leg ahead together - Weight is being supported by the stronger leg 2. Move the stronger leg ahead - Weight is being supported by the affected leg and both arms

You are caring for a patient after surgery who had a liver resection. His prothrombin time (PT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions do you perform? (Select all that apply.) 1. Notify the surgeon. 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes. 4. Wean oxygen therapy. 5. Provide comfort through bathing.

1. Notify the surgeon. 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1. Notify the surgeon. 4. Cover the area with sterile, saline-soaked towels immediately.

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep.

1. Only the patient should push the button. 3. The PCA system can set limits to prevent overdoses from occurring. 5. Do not push the button to go to sleep.

Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. Adult who has consumed alcoholic beverages 4. Adolescent waking from sleep 5. Three-pack-per-day smoker with pneumonia

1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 5. Three-pack-per-day smoker with pneumonia

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1. Patient's self-report 2. Behaviors 3. Surrogate (wife) report 4. Vital sign changes

1. Patient's self-report

Before transferring a patient from the bed to a stretcher, which assessment data do the nurse need to gather? (Select all that apply.) 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. Nutritional intake

1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment

A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply.) 1. People who are homeless. 2. People with respiratory conditions. 3. People with cardiovascular conditions. 4. The very old. 5. People with kidney disorders.

1. People who are homeless. 3. People with cardiovascular conditions. 4. The very old.

Donning Sterile Gloves

1. Perform thorough hand hygiene. 2. Remove outer glove package wrapper by carefully separating and peeling apart sides. 3. Grasp inner package and lay it on clean, flat surface just above waist level. Open package, keeping gloves on wrappers inside surface. Open package touching only 1-inch border: make sure the gloves stay on wrapper. 4. Identify right and left glove. Each glove has cuff approximately 5 cm (2 inches) wide. Glove dominant hand first. 5. With thumb and first two fingers of nondominant hand, grasp edge of cuff of glove for dominant hand. Touch only inside surface of glove. 6. Carefully pull glove over dominant hand, leaving cuff and being sure that it does not roll up wrist. Be sure that thumb and fingers are in proper spaces 7. With gloved dominant hand, slip fingers underneath cuff of second glove 8. Carefully pull second glove over nondominant hand. Do not allow fingers and thumb of gloved dominant hand to touch any part of exposed nondominant hand. Keep thumb of dominant hand abducted back 9. After second glove is on, interlock fingers of gloved hands and hold away from body above waist level until beginning procedure

At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first? 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to resume normal operations 4. Evacuate patients per the disaster plan

1. Prepare for an influx of patients

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

10. The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? 1. Raise the head of the bed to 45 degrees or higher. 2. Get the oxygen saturation with a pulse oximeter. 3. Take the blood pressure and respiratory rate. 4. Notify the health care provider of the shortness of breath.

1. Raise the head of the bed to 45 degrees or higher.

After a patient has been given preoperative sedatives, which safety precaution do you take? 1. Reinforce to patient to remain in bed or on the stretcher 2. Raise the side rails and keep the bed or stretcher in the high position 3. Determine if patient has any allergies to latex 4. Obtain informed consent immediately after sedative administration

1. Reinforce to patient to remain in bed or on the stretcher

A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? 1. Right antecubital and tympanic membrane 2. Right popliteal and rectal 3. Left antecubital and oral 4. Left popliteal and temporal artery

1. Right antecubital and tympanic membrane

The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures do nurses in these areas implement to prevent a latex reaction? (Select all that apply.) 1. Screen patients about food allergies known to have cross-reactivity to latex. 2. Have a latex allergy cart available at all times. 3. Communicate with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a patient with latex sensitivity is identified. 4. Schedule the patient with a latex allergy for the last operative case of the day. 5. Plan for the patient to be admitted to a private room after surgery.

1. Screen patients about food allergies known to have cross-reactivity to latex. 2. Have a latex allergy cart available at all times. 3. Communicate with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a patient with latex sensitivity is identified.

A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) 1. Sharing information about senior transportation services 2. Reassuring the patient that loneliness is a normal part of aging 3. Maintaining distance while talking to avoid overstimulating the patient 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

1. Sharing information about senior transportation services 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply.) 1. Sharp pleuritic pain that worsens on inspiration 2. Crackles over lung bases of affected lung 3. Tracheal deviation toward the affected lung 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side

1. Sharp pleuritic pain that worsens on inspiration 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) 1. SpO2 levels 2. Amount, color, and consistency of sputum production 3. Fluid status 4. Change in respiratory rate and pattern 5. Pain in lower leg

1. SpO2 levels 2. Amount, color, and consistency of sputum production 4. Change in respiratory rate and pattern

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What is your priority nursing intervention? 1. Stop the instillation 2. Ask the patient to take deep breaths to decrease the pain 3. Add soapsuds to the enema 4. Tell the patient to bear down as he would when having a bowel movement

1. Stop the instillation

The nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat the large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil (Provigil).

1. Take brief, 20-minute naps no more than twice a day. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil (Provigil).

A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) 1. Teaching how activities such as reading and using crossword puzzles provide stimulation 2. Moving him to a room away from the nurse's station 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions 5. Providing auditory stimulation for the patient by keeping the television on continuously

1. Teaching how activities such as reading and using crossword puzzles provide stimulation 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions

Characteristics of correct body alignment for the standing patient include the following:

1. The head is erect and midline. 2. When observed posteriorly, the shoulders and hips are straight and parallel. 3. When observed posteriorly, the vertebral column is straight. 4. When observed laterally, the head is erect, and the spinal curves are aligned in a reversed S pattern. The cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, and the lumbar vertebrae are anteriorly convex. 5. When observed laterally, the abdomen is comfortably tucked in, and the knees and ankles are slightly flexed. The person appears comfortable and does not seem conscious of the flexion of knees or ankles. 6. The arms hang comfortably at the sides. 7. The feet are slightly apart to achieve a base of support, and the toes are pointed forward. 8. When viewing the patient from behind, the center of gravity is in the midline, and the line of gravity is from the middle of the forehead to a midpoint between the feet. Laterally the line of gravity runs vertically from the middle of the skull to the posterior third of the foot

Characteristics of correct alignment of the sitting patient include the following:

1. The head is erect, and the neck and vertebral column are in straight alignment. 2. The body weight is distributed evenly on the buttocks and thighs. 3. The thighs are parallel and in a horizontal plane. 4. Both feet are supported on the floor, and the ankles are flexed comfortably. With patients of short stature, use a footstool to ensure that ankles are flexed comfortably. 5. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. This space ensures that there is no pressure on the popliteal artery or nerve to decrease circulation or impair nerve function. 6. The patient's forearms are supported on the armrest, in the lap, or on a table in front of the chair. *It is particularly important to assess alignment when sitting if the patient has muscle weakness, muscle paralysis, or nerve damage. Patients who have these problems have diminished sensation in the affected area and are unable to perceive pressure or decreased circulation. Proper alignment while sitting reduces the risk of musculoskeletal system damage in such a patient. The patient with severe respiratory disease sometimes assumes a posture of leaning on the table in front of the chair in an attempt to breathe more easily. This is called orthopnea.

A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body.

1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves.

A postoperative patient currently is asleep. Therefore the nurse knows that: 1. The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. 3. Pain assessment is not necessary. 4. The patient can be switched to the same amount of medication by the oral route.

1. The sedative administered may have helped him sleep, but it is still necessary to assess pain.

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1. To relieve edema 3. To improve blood flow to an injured part

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions

2. Droplet precautions

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction

1. Transcutaneous electrical nerve stimulation (TENS) 3. Provide back massage 4. Reposition the patient

What assessment does a nurse make before hanging an intravenous (IV) fluid that contains potassium? 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Level of consciousness

1. Urine output

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device (e.g., transfer board) 3. Have head of bed flat when repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) 1. Use antimicrobial toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

1. Use antimicrobial toothpaste. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. 4. Use a soft toothbrush for oral care.

A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. Use tap water to clean soft lenses. 2. Follow recommendations of lens manufacturer when inserting the lenses. 3. Keep lenses moist or wet when not worn. 4. Use fresh solution daily when storing and disinfecting lenses.

1. Use tap water to clean soft lenses.

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit need to be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? (Select all that apply.) 1. Vital signs, type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 3. Verification of the patient using one identifier and the type of surgery performed 4. Review of pertinent events occurring in the operating room (OR) while at the nurses' station 5. Location of patient's family members

1. Vital signs, type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 5. Location of patient's family members

A nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress 2. Monitor the patient's blood pressure 3. Aspirate the infusing fluid from the VAD 4. Stop the infusion and discontinue the intravenous infusion

4. Stop the infusion and discontinue the intravenous infusion

Braden Scale: High risk

10 to 12 *Consider protocol that increases frequency of turning; supplements turning with small shifts in position; facilitates maximal remobilization; protects patient's heels; provides pressure-redistribution surface; provides foam wedges for 30-degree lateral positioning; and manages moisture, friction, and shear. If needed, institute nutritional interventions to reduce risk of pressure ulcer development.

2.2 lbs gain or lost is equal to

1000 liters of fluid

Braden Scale: Moderate risk

13 to 14 *Consider protocol of frequent turning; protecting patient's heels; providing pressure-redistribution surface; providing foam wedges for 30-degree lateral positioning; and managing moisture, shear, and friction.

Braden Scale: At risk general population

15 to 18 13 at risk ICU patients *Consider instituting frequent turning, protecting patient's heels, using a pressure-redistribution surface, and managing moisture.

3. What statement made by a 4-year-old patient's mother indicates that she understands how to administer her son's eardrops? 1. "To straighten his ear canal, I need to pull the outside part of his ear down and back." 2. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." 3. "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops." 4. "After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at least 10 minutes."

2. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward."

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolpidem (Ambien) to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F).

2, 1, 4, 3 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F). 3. "I'm calling to ask if you would order a hypnotic such as zolpidem (Ambien) to use on a prn basis."

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex.

2, 5, 1, 3, 6, 4 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 5. Remove partial plate or dentures if present. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 6. Gently brush tongue but avoid stimulating gag reflex. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity.

A patient is prescribed morphine patient-controlled analgesia (PCA). Arrange the following steps for administering PCA in the correct order. 1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly. 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into injection port nearest patient.

2, 5, 1, 4, 6, 3 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly. 5. Identify patient using two identifiers. 1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 6. Insert and secure needleless adapter into injection port nearest patient. 3. Administer loading dose of analgesia as prescribed.

The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of intravenous (IV) tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port. 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

2, 5, 4, 6, 1, 3 2. Select injection port of intravenous (IV) tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 5. Clean injection port with antiseptic swab. Allow to dry. 4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port. 6. Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate.

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are better than prescription medications because these can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."

2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls."

Which of the following cause Clostridium difficile infection? (Select all that apply.) 1. Chronic laxative use 2. Contact with C. difficile bacteria 3. Overuse of antibiotics 4. Frequent episodes of diarrhea caused by food intolerance 5. Inflammation of the bowel

2. Contact with C. difficile bacteria 3. Overuse of antibiotics

Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age? 1. "You are never too old to begin an exercise program." 2. "My granddaughter and I walk together around the high school track 3 times a week." 3. "I purchased a subscription to a runner's magazine for my grandson for Christmas." 4. "When I was a child, I exercised more than I see kids doing today."

2. "My granddaughter and I walk together around the high school track 3 times a week."

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? 1. "I'll give the baby a bottle to help her fall asleep." 2. "We'll place the baby on her back to sleep." 3. "We put the baby's stuffed animals in the crib to make her feel safe." 4. "I know the baby will not need to be fed until morning."

2. "We'll place the baby on her back to sleep."

Which of the following nursing actions do you take after placing a bedpan under an immobilized patient? 1. Lift the patient's hips off the bed and slide the bedpan under the patient 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle 3. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient 4. Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed

2. . After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle

Which patients does a nurse plan to teach regarding water restriction? 1. A 23-year-old with extracellular fluid volume (ECV) deficit 2. A 34-year-old with hyponatremia 3. A 47-year-old with hypercalcemia 4. A 69-year-old with metabolic acidosis

2. A 34-year-old with hyponatremia

You are assigned to care for the following patients on your surgical unit. On the basis of the information provided, which patient do you need to see first? 1. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 2. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.) 3. A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic 4. A 48-year-old following total knee replacement who needs help repositioning in bed

2. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.)

Which is the correct gait when a patient is ascending stairs on crutches? 1. A modified two-point gait. (The affected leg is advanced between the crutches to the stairs.) 2. A modified three-point gait. (The unaffected leg is advanced between the crutches to the stairs.) 3. A swing-through gait 4. A modified four-point gait. (Both legs advance between the crutches to the stairs.)

2. A modified three-point gait. (The unaffected leg is advanced between the crutches to the stairs.)

You are working in a health clinic on a college campus. You need to administer medroxyprogesterone acetate intramuscularly (IM) to a female patient for birth control. You look up this medication in a reference manual and determine that it is viscous and injections can be painful. On the basis of this information, you plan which of the following when administering this medication? (Select all that apply.) 1. Inject the medication over 3 minutes to reduce pain associated with the injection 2. Administer the medication in the ventral gluteal site 3. Use the Z-track method when administering the medication 4. Use the deltoid site for medication administration 5. Ask the patient questions about her major and which classes she is taking during the injection to provide distraction

2. Administer the medication in the ventral gluteal site 3. Use the Z-track method when administering the medication 5. Ask the patient questions about her major and which classes she is taking during the injection to provide distraction

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal

2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the first postoperative day

2. Ambulate patient to chair in the hall

You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, his heart rate is 110. What is your next action? 1. Stop exercise immediately and have him sit in a nearby chair. 2. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. 3. Tell him that he needs to walk further to reach a heart rate of 120. 4. Have him walk slower; he has reached his maximum.

2. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise.

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

2. Assess skin for redness, abrasions, and open areas daily. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? 1. Have patient follow hospital routines. 2. Avoid waking patient for nonessential tasks. 3. Give prescribed sleeping medications at dinner. 4. Turn television on low to late-night programming.

2. Avoid waking patient for nonessential tasks.

After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to: 1. Follow ISMP guidelines for safe medication abbreviations. 2. Explain to the health care provider that the order needs to be given to a registered nurse. 3. Write down the order on the patient's order sheet and read it back to the health care provider. 4. Ensure that the six rights of medication administration are followed when giving the medication.

2. Explain to the health care provider that the order needs to be given to a registered nurse.

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: 1. Stimulates hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to overinflate, leading to atelectasis

2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs

A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.) 1. Walk one-half step behind and slightly to her side. 2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs. 4. Stand one step ahead of mom at the top of the stairs. 5. Place yourself alongside your mom and hold onto her waist.

2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs.

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

2. Ice bag

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning.

2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.

Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) 1. Set up sterile field before patient and other staff come to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed.

2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

Which of the following skills can the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1. Nasotracheal suctioning 2. Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4. Permanent tracheostomy tube suctioning 5. Care of an endotracheal tube

2. Oropharyngeal suctioning of a stable patient 4. Permanent tracheostomy tube suctioning

The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) 1. Repositioning and retaping a patient's nasogastric tube 2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours 4. Administering enteral feeding bolus after tube placement has been verified 5. Hanging a new bag of enteral feeding

2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? 1. Fastening tube to the gown with new tape 2. Placing patient supine while giving a bath 3. Hanging a new container of enteral feeding 4. Ambulating patient with enteral feedings still infusing

2. Placing patient supine while giving a bath

Which of the following most motivates a patient to participate in an exercise program? 1. Providing a patient with a pamphlet on exercise 2. Providing information to the patient when he or she is ready to change behavior 3. Explaining the importance of exercise at the time of diagnosis of a chronic disease 4. Providing the patient with a booklet with examples of exercises 5. Providing the patient with a prescribed exercise program

2. Providing information to the patient when he or she is ready to change behavior

The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? 1. Checking distal pulses 2. Providing range-of-motion (ROM) exercises to extremities 3. Determining type of treatment for stage 1 pressure ulcer 4. Changing the dressing over an intravenous site

2. Providing range-of-motion (ROM) exercises to extremities

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Providing support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision

A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia? (Select all that apply.) 1. Loss of sensation at the surgical site 2. Reduction of fear and anxiety 3. Amnesia about procedure 4. Monitoring in phase I recovery 5. Close monitoring for airway patency

2. Reduction of fear and anxiety 3. Amnesia about procedure

The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately 2. Repeat the measurements on both arms using a stethoscope 3. Ask the patient if she has taken her blood pressure medications recently 4. Obtain blood pressure measurements on lower extremities 5. Verify that the correct cuff size was used during the measurements 6. Review the patient's record for her baseline vital signs 7. Compare right and left radial pulses for strength

2. Repeat the measurements on both arms using a stethoscope 6. Review the patient's record for her baseline vital signs

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

2. Request to have the order changed to around the clock (ATC) for the first 48 hours.

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication

2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation

A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was yesterday. What is the appropriate action for the nursing student to take next? 1. Ask the nursing professor for advice 2. Return the medication to pharmacy and get another tablet 3. Call the health care provider after discussing this situation with the charge nurse 4. Administer the medication since medications are good for 30 days after their expiration date

2. Return the medication to pharmacy and get another tablet

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (Select all that apply.) 1. Heart disease. 2. Sepsis. 3. Pleural effusion. 4. Cardiac arrhythmias. 5. Diarrhea.

2. Sepsis. 3. Pleural effusion. 4. Cardiac arrhythmias.

The nurse is providing health teaching for a patient using herbal compounds such as kava for sleep. Which points need to be included? (Select all that apply.) 1. Can cause urinary retention 2. Should not be used indefinitely 3. May have toxic effects on the liver 4. May cause diarrhea and anxiety 5. Are not regulated by the U.S. Food and Drug Administration (FDA)

2. Should not be used indefinitely 3. May have toxic effects on the liver 5. Are not regulated by the U.S. Food and Drug Administration (FDA)

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) 1. Prone position 2. Sims' position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position

2. Sims' position 3. Semi-Fowler's position with head to side

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program

2. Start a scheduled toileting program

Which patients are at high risk for nutritional deficits? (Select all that apply.) 1. The divorced computer programmer who eats precooked food from the local restaurant 2. The middle-age female with celiac disease who does not follow her gluten-free diet 3. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements 5. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal

2. The middle-age female with celiac disease who does not follow her gluten-free diet 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements

When should a nurse wear a mask? (Select all that apply.) 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter.

2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter.

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because: 1. He or she needs to get the patient into the operating room (OR) quickly to start the surgery because of the low BP. 2. The surgery may need to be delayed to recheck the patient's WBC count and investigate the source of fever before surgery. 3. The nurse anticipates the need for a fluid bolus to increase the patient's BP. 4. The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.

2. The surgery may need to be delayed to recheck the patient's WBC count and investigate the source of fever before surgery.

A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient? 1. Two-point gait 2. Three-point gait 3. Four-point gait 4. Swing-through gait

2. Three-point gait

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply.) 1. Use of fluorescent lighting 2. Use of warm, incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies 5. Indirect lighting to reduce glare

2. Use of warm, incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies

Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.) 1. Risk for bleeding is increased. 2. Ventilatory capacity is reduced. 3. Fatty tissue has a poor blood supply. 4. Metabolic demands are increased. 5. Physical mobility is often impaired.

2. Ventilatory capacity is reduced. 3. Fatty tissue has a poor blood supply. 5. Physical mobility is often impaired.

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.) 1. If patient is standing, attempt to get him or her back in bed. 2. With patient on floor, clear surrounding area of furniture or equipment. 3. If possible, keep patient lying supine. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.

2. With patient on floor, clear surrounding area of furniture or equipment. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the correct order: 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support.

3, 1, 2, 5, 6, 4 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support. 4. Check time elapsed.

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order. 1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly. 3. Identify patient using two identifiers. 4. Introduce self and ask patient about his feelings of being restrained. 5. Assess condition of skin where restraint will be placed.

3, 4, 1, 5, 2 3. Identify patient using two identifiers. 4. Introduce self and ask patient about his feelings of being restrained. 1. Be sure that patient is comfortable with arm in anatomic alignment. 5. Assess condition of skin where restraint will be placed. 2. Wrap wrist with soft part of restraint toward skin and secure snugly.

A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? 1. Tell patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 5. Position patient's hand on back of chair.

3, 4, 2, 1, 5 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 2. Walk at a relaxed pace. 1. Tell patient when you are approaching the chair. 5. Position patient's hand on back of chair.

A nursing assistive personnel asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? 1. "As long as we use proper body mechanics, no one will get hurt." 2. "The patient only weighs 125 lbs. You don't need my assistance." 3. "Call the lift team for additional assistance." 4. "The two of us can lift the patient easily."

3. "Call the lift team for additional assistance."

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? 1. "I'll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear." 2. "Sleep medicines won't cause any sleep problems once I stop taking them." 3. "I'll talk to my health care provider before I use an over-the-counter sleep medication." 4. "I'll contact my health care provider if I feel extremely sleepy in the mornings."

3. "I'll talk to my health care provider before I use an over-the-counter sleep medication."

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. "I feel refreshed when I wake up in the morning." 2. "I use soft music at night to help me relax." 3. "It takes me about 45 to 60 minutes to fall asleep." 4. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

3. "It takes me about 45 to 60 minutes to fall asleep."

The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? 1. 96/40 mm Hg 2. 110/66 mm Hg 3. 130/90 mm Hg 4. 156/82 mm Hg

3. 130/90 mm Hg *Inflating too slowly = high false diastolic pressure

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who just returned to the nursing unit from a diagnostic test 2. A patient who prefers a bath in the evening when his wife visits and can help him 3. A patient who is experiencing frequent incontinent diarrheal stools and urine 4. A patient who has been awake all night because of pain 8/10

3. A patient who is experiencing frequent incontinent diarrheal stools and urine

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bed sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert image inch more.

3. Advance the catheter to the bifurcation of the drainage and balloon ports.

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? 1. Request that the nursing assistant repeat the pulse check 2. Call for a stat electrocardiogram (ECG) 3. Assess the patient's apical pulse and evidence of a pulse deficit 4. Prepare to administer cardiac-stimulating medications

3. Assess the patient's apical pulse and evidence of a pulse deficit

The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea (OSA). Which intervention is appropriate to include on the plan? 1. Instruct the patient to sleep in a supine position. 2. Have patient limit fluid intake 2 hours before bedtime. 3. Elevate head of bed and assume a side or prone position. 4. Encourage patient to take an over-the-counter sleep aid.

3. Elevate head of bed and assume a side or prone position.

An elderly patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? 1. Talk to the patient at a distance so he or she may read your lips. 2. Keep your arms at your side; speak directly into the patient's left ear. 3. Face the patient when speaking; demonstrate ideas you wish to convey. 4. Position the patient so the light is on his or her face when speaking.

3. Face the patient when speaking; demonstrate ideas you wish to convey.

Which assessment does a nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Presence or absence of edema 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. Fullness of neck veins when supine

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Are your bowel movements soft and formed? 3. Have you experienced frequent, small liquid stools recently? 4. Have you taken antibiotics recently?

3. Have you experienced frequent, small liquid stools recently?

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern

3. Intermittent fever pattern

Which of the following is a principle of proper body mechanics when lifting or carrying objects? (Select all that apply.) 1. Keep the knees in a locked position. 2. Bend at the waist to maintain a center of gravity. 3. Maintain a wide base of support. 4. Hold objects away from the body for improved leverage. 5. Encourage patient to help as much as possible.

3. Maintain a wide base of support. 5. Encourage patient to help as much as possible.

As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? 1. Nail polish attracts microorganisms and contaminates the finger sensor. 2. Nail polish increases oxygen saturation. 3. Nail polish interferes with sensor function. 4. Nail polish creates excessive heat in sensor probe.

3. Nail polish interferes with sensor function.

A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: 1. Community mouthwash. 2. Alcohol-based mouth rinse. 3. Normal saline rinses. 4. Firm toothbrush.

3. Normal saline rinses.

When delegating input and output (I&O) measurement to nursing assistive personnel, a nurse instructs them to record what information for ice chips? 1. The total volume 2. Two-thirds of the volume 3. One-half of the volume 4. One-quarter of the volume

3. One-half of the volume

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) 1. Conducting a home-safety assessment and identifying hazards in the patient's living environment 2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status

3. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

3. Radiation therapy 4. Dehydration

Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

3. Report the time and amount of first voiding.

Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, the American Nurses Association advocates which of the following? 1. Mandate that physical therapists do all patient transfers 2. Require adequate staffing levels in health care organizations 3. Require the use of assistive equipment and devices 4. Require an adequate number of staff to be involved in all patient transfers

3. Require the use of assistive equipment and devices

When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply.) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

3. Respirations 4. Gag reflex

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and image, 24. The nurse interprets these laboratory values to indicate: 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Respiratory acidosis. 4. Respiratory alkalosis.

3. Respiratory acidosis.

A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next? 1. Give the medications after identifying the patient using two patient identifiers 2. Provide medication education to the patient to help with adherence to the medical plan 3. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications 4. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital

3. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications

Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: 1. Avoid activities in which there may be crowds. 2. Delay childhood immunizations until hearing can be verified. 3. Take precautions when involved in activities associated with high-intensity noises. 4. Prophylactically administer antibiotics to reduce the incidence of infections.

3. Take precautions when involved in activities associated with high-intensity noises.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.) 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient? 1. The patient keeps the cane on the left side of the body. 2. The patient slightly leans to one side while walking. 3. The patient keeps two points of support on the floor at all times. 4. After the patient places the cane forward, he or she then moves the right leg forward to the cane.

3. The patient keeps two points of support on the floor at all times.

Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia? 1. Ask open-ended questions 2. Speak to the patient as if he or she is a child 3. Use a dry-erase board or paper and pen for writing messages 4. Avoid the use of gestures and other nonverbal forms of communication

3. Use a dry-erase board or paper and pen for writing messages

The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place your care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.

4, 1, 3, 2, 5 4. Assess the patient's mental status. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 3. Check the patient's pulse distal to the blood pressure cuff. 2. Obtain a manual blood pressure with a stethoscope. 5. Remind the patient not to bend her arm with the blood pressure cuff.

A patient's surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order? 1. Notify the health care provider of the patient's status. 2. Reassure the patient and recheck the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing.

4, 2, 1, 3, 4. Use aseptic technique to change the dressing. 2. Reassure the patient and recheck the wound later. 1. Notify the health care provider of the patient's status. 3. Support the patient's fluid and nutritional needs.

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place waterproof bag near bed. 5. Position angiocatheter over wound.

4, 3, 2, 5, 1 4. Place waterproof bag near bed. 3. Fill syringe with irrigation fluid. 2. Attach 19-gauge angiocatheter to syringe. 5. Position angiocatheter over wound. 1. Use slow, continuous pressure to irrigate wound.

Place the following in correct sequence for suctioning a patient. 1. Open kit and basin 2. Apply gloves 3. Lubricate catheter 4. Verify functioning of suction device and pressure 5. Connect suction tubing to suction catheter 6. Increase supplemental oxygen 7. Reapply oxygen 8. Suction airway

4, 6, 1, 3, 2, 5, 8, 7 4. Verify functioning of suction device and pressure 6. Increase supplemental oxygen 1. Open kit and basin 3. Lubricate catheter 2. Apply gloves 5. Connect suction tubing to suction catheter 8. Suction airway 7. Reapply oxygen

Which statement made by the patient indicates a need for further teaching on sleep hygiene? 1. "I'm going to do my exercises before I eat dinner." 2. "I'm going to go to bed every night at about the same time." 3. "I set my alarm to get up at the same time every morning." 4. "I moved my computer to the bedroom so I could work before I go to sleep."

4. "I moved my computer to the bedroom so I could work before I go to sleep."

A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education? 1. "I'll make sure that I rest between activities so I don't get so short of breath." 2. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." 3. "If I have trouble breathing at night, I'll use two or three pillows to prop up." 4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4. A dressing that forms a gel that interacts with the wound surface

A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? 1. A medication cup 2. A teaspoon 3. A 5-mL syringe 4. An oral-dosing syringe

4. An oral-dosing syringe

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: 1. Palpable, elevated hardened area around a tuberculosis skin testing site 2. Sputum for culture and sensitivity identifies mycobacterium tuberculosis 3. Presence of acid-fast bacilli in sputum 4. Arterial oxygen tension (PaO2) of 95 mm Hg

4. Arterial oxygen tension (PaO2) of 95 mm Hg

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority? 1. Complete an occurrence report. 2. Notify the health care provider. 3. Inform the charge nurse of the error. 4. Assess the patient for adverse effects.

4. Assess the patient for adverse effects.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

4. Cleansed wound

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? 1. TENS works by causing distraction. 2. TENS therapy does not require a health care provider's order. 3. TENS requires an electrical source for use. 4. TENS electrodes are applied near or directly on the site of pain.

4. TENS electrodes are applied near or directly on the site of pain.

A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? 1. Direct the NAP to hold the thermometer in place with her gloved hand 2. Direct the NAP to switch the thermometer probe to the left sublingual pocket 3. Direct the NAP to obtain a right tympanic temperature 4. Direct the NAP to use a temporal artery thermometer from right to left

4. Direct the NAP to use a temporal artery thermometer from right to left

A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 0900. What is the appropriate nursing action? 1. Assess bowel sounds 2. Raise the head of the bed to at least 45 degrees 3. Position the patient on his or her right side to promote stomach emptying 4. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

4. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

Because an older adult is at increased risk for respiratory complications after surgery, the nurse needs to: 1. Withhold pain medications and ambulate the patient every 2 hours. 2. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours. 3. Orient the patient to the surrounding environment frequently and ambulate him or her every 2 hours. 4. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control.

4. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control.

Which statement made by a patient of a 2-month-old infant requires further education? 1. I'll continue to use formula for the baby until he is a least a year old. 2. I'll make sure that I purchase iron-fortified formula. 3. I'll start feeding the baby cereal at 4 months. 4. I'm going to alternate formula with whole milk starting next month.

4. I'm going to alternate formula with whole milk starting next month.

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? 1. Sonorous wheezes in the left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles in lung bases

4. Inspiratory crackles in lung bases

Your patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the patient has? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4. Lactose intolerance

You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated? 1. Infection: Notify surgeon and anticipate administration of antibiotics. 2. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. 3. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. 4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.

4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity. 2. Opioid tolerance. 3. Opioid addiction. 4. Opioid withdrawal.

4. Opioid withdrawal.

In the postanesthesia care unit (PACU) a nurse notes that a patient is having difficulty breathing and suspects an upper-airway obstruction. The nurse's priority intervention at this time is: 1. Suction the pharynx and bronchial tree. 2. Give oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.

4. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the health care provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

A patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis

The nurse is administering a benzodiazepine sleep aid to an older adult. What should be the priority assessment for the patient? 1. Incontinence 2. Nausea and vomiting 3. Bradycardia 4. Respiratory depression

4. Respiratory depression

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1. Activity Intolerance 2. Impaired Bed Mobility 3. Acute Pain 4. Risk for Falls

4. Risk for Falls

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat 2. Turn her on their side 3. Put on oxygen at 2-L nasal cannula 4. Stop feeding her and place on NPO

4. Stop feeding her and place on NPO

A nursing student is administering medications to a patient through a gastric tube (G-tube). Which of the following actions taken by the nursing student requires the nursing instructor to intervene? 1. The nursing student places all the patient's medications in different medicine cups. 2. The nursing student evaluates each medication and holds the tube feeding before administering a medication that needs to be administered on an empty stomach. 3. The nursing student flushes the tube with 30 mL of water between each medication. 4. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it.

4. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it.

A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? 1. Only infants and toddlers need to ride in the back seat. 2. All toddlers can move to a forward facing car seat when they reach age 2. 3. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. 4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: 1. Gastric motility, thereby facilitating glucose digestion. 2. Respiratory effort, thereby decreasing activity intolerance. 3. Overall cardiac output, thereby resuming resting heart rate. 4. Use of glucose and fatty acids, thereby decreasing blood glucose level.

4. Use of glucose and fatty acids, thereby decreasing blood glucose level.

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings

4. When 75% of the patient's nutritional needs are met by the tube feedings

The nurse is caring for a patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits and continue a normal lifestyle? 1. Encourage the patient to rearrange her home furnishings regularly to keep active. 2. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility. 3. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. 4. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.

4. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.

What quantity of urine in bladder will stimulate the urge to void?

400 to 600 mL of urine in bladder.

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5, 7, 2, 4, 1, 6, 3, 8, 9 5. Drape patient with the sterile square and fenestrated drapes. 7. Prepare sterile field and supplies. 2. Lubricate catheter. 4. Cleanse urethral meatus with antiseptic solution. 1. Insert and advance catheter. 6. When urine appears, advance another 2.5 to 5 cm. 3. Inflate catheter balloon. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

10. Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.

6, 4, 2, 1, 5, 3, 7 6. Carefully check the health care provider's order. 4. Use two identifiers to ensure correct patient. 2. Explain procedure to patient. 1. Perform hand hygiene and apply gloves. 5. Stop the infusion and clamp the tubing. 3. Remove IV site dressing and tape. 7. Clean the site, withdraw the catheter, and apply pressure.

Place the steps to administering a prepackaged enema the correct order. 1. Insert enema tip gently in the rectum. 2. Help patient to bathroom when he or she feels urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient.

6, 4, 3, 1, 5, 2, 6. Explain procedure to the patient. 4. Perform hand hygiene and apply clean gloves. 3. Position patient on side. 1. Insert enema tip gently in the rectum. 5. Squeeze contents of container into rectum. 2. Help patient to bathroom when he or she feels urge to defecate.

The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. Place the following steps in order to perform this procedure. 1. Place patient in high-Fowler's position. 2. Have patient flex head toward chest. 3. Assess patient's gag reflex. 4. Determine length of the tube to be inserted. 5. Obtain radiological confirmation of tube placement. 6. Check pH of gastric aspirate for verifying placement. 7. Identify patient with two identifiers.

7, 1, 3, 4, 2, 5, 6 7. Identify patient with two identifiers. 1. Place patient in high-Fowler's position. 3. Assess patient's gag reflex. 4. Determine length of the tube to be inserted. 2. Have patient flex head toward chest. 5. Obtain radiological confirmation of tube placement. 6. Check pH of gastric aspirate for verifying placement.

A child is taking albuterol through a pressurized metered-dose inhaler (pMDI) that contains a total of 64 puffs. The dose is 2 puffs every 6 hours. How many days will the pMDI last? ___________ days.

8

Braden Scale: Very high risk

9 or below *Consider protocol that incorporates points for high-risk patients and uses pressure-redistribution surface if patient has intractable pain or severe pain exacerbated by turning.

Skin/Temporal artery - surface - average temperature

96.7 avg

Acceptable temperature range for an adult is:

96.8 F to 100.4 F

Cheyne-Stokes respiration

A type of abnormal breathing. It's characterized by a gradual increase in breathing, and then a decrease. This pattern is followed by a period of apnea where breathing temporarily stops. The cycle then repeats itself.

Therapeutic effect

= Desired effect - Reason drug is prescribed

Stat order

A STAT order signifies that a single dose of a medication is to be given immediately and only once.

Carbon monoxide

A colorless, odorless gas that can cause sudden illness and death

Sleep apnea

A disorder characterized by lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep. Three types of sleep apnea are known: central, obstructive, and mixed. The most common form is obstructive. *Treatment includes therapy for underlying cardiac or respiratory complications and emotional problems that occur as a result of the symptoms of this disorder.

Now order:

A now order is more specific than a 1-time order and is used when a patient needs a medication quickly but not right away, as in a STAT order. When receiving a now order, the nurse has up to 90 minutes to administer the medication. Only administer now medications 1 time.

Body system defenses:

A number of body organ systems have unique defenses against infection. The skin, respiratory tract, and GI tract are easily accessible to microorganisms. Pathogenic organisms can adhere to the surface skin, be inhaled into the lungs, or be ingested with food. Each organ system has defense mechanisms physiologically suited to its specific structure and function. For example, the lungs cannot completely control the entrance of microorganisms. However, the airways are lined with moist mucous membranes and hairlike projections, or cilia, that rhythmically beat to move mucus or cellular debris up to the pharynx to be expelled through swallowing.

Constipation

A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in the use of a metered-dose inhaler? A. "Be sure to let me know if she starts coughing again." B. "Show the patient how to clean the spacer chamber after she's finished with the inhaler." C. "Offer the patient her inhaler if it looks like she's short of breath." D. "Please tell her the inhaler is to be used no more than three times per day."

A. "Be sure to let me know if she starts coughing again."

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in the use of a dry powder inhaler (DPI)? A. "Be sure to let me know if the patient starts coughing again." B. "Did you shake the inhaler well before giving it to the patient?" C. "Do you think the patient is capable of using the inhaler independently?" D. "Please tell the patient that the inhaler is to be used only when she is having trouble breathing."

A. "Be sure to let me know if the patient starts coughing again."

The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute? A. 25 drops/minute B. 30 drops/minute C. 35 drops/minute D. 40 drops/minute

A. 25 drops/minute

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A. A 28-year-old patient who fractured a femur after heavy drinking. B. A 73-year-old patient who is on anticoagulation therapy. C. A 54-year-old patient who broke a cheekbone in a fall. D. A 67-year-old patient with a history of unexplained nosebleeds.

A. A 28-year-old patient who fractured a femur after heavy drinking. Neither the patient's broken femur nor the patient's alcohol consumption would contraindicate placement of a nasogastric tube. A 73-year-old patient on anticoagulation therapy would be at high risk for bleeding, which is a contraindication for tube feeding. A 54-year-old patient with facial trauma is a contraindication for a nasogastric tube. A 67-year-old patient with unexplained nosebleeds would contraindicate placement of a nasogastric tube.

For which patient would the nurse most likely ask for a podiatrist consult for nail care? A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot. B. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladder. C. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floor. D. A 12-year-old girl with a broken foot.

A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot.

When preparing to administer heparin or insulin subcutaneously, which site is preferred? A. Abdomen B. Scapula C. Deltoid muscle D. Back of the upper arm

A. Abdomen

The nurse is concerned that a confused patient's erratic movements may compromise the intravenous (IV) insertion site. Which action can the nurse take to protect the patient and the site from injury? A. Apply an IV site-protection device over the site, such as House Ultra Dressing. B. Apply restraints to the patient. C. Check the patient frequently. D. Instruct the patient to avoid dislodging the IV catheter.

A. Apply an IV site-protection device over the site, such as House Ultra Dressing.

A nurse is preparing to help a patient administer a mucolytic agent using a metered-dose inhaler (MDI). What will the nurse do first in order to evaluate the medication's effectiveness? A. Assess the patient's respiratory status before administration. B. Warn against overuse of the inhaler. C. Discuss the side effects of the particular drug. D. Verify the patient's identification according to agency policy.

A. Assess the patient's respiratory status before administration.

The nurse is preparing to help a patient use a dry powder inhaler. What will the nurse do first in order to evaluate the medication's effectiveness? A. Assess the patient's respiratory status. B. Warn the patient against overuse of the inhaler. C. Discuss the side effects of the particular drug. D. Verify the patient's identity according to agency policy.

A. Assess the patient's respiratory status.

When turning a patient to place a slide board, where do the assistants stand? A. At the side of the bed to which the patient will be turned B. At the side of the bed from which the patient will be turned C. At the head and foot of the bed D. At the foot of the bed only

A. At the side of the bed to which the patient will be turned

The provider has ordered that a patient be 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion? A. Calculate the hourly volume of normal saline the patient should receive. B. Determine the drop factor of the tubing that will be used for the infusion. C. Calculate the drops per minute at which the tubing will be regulated. D. Determine the drops per mL that the tubing will deliver.

A. Calculate the hourly volume of normal saline the patient should receive.

Which patient safety issue is specific to administration of medication by IV bolus? A. Determining that the medication is compatible with the IV solution B. Checking for patient allergies before giving the medication C. Identifying the patient using two identifiers D. Checking the medication against the medication administration record (MAR) three times

A. Determining that the medication is compatible with the IV solution * Medication that is incompatible with the running IV solution could form a precipitate and endanger the patient's health.

Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? A. Elevating the head of the bed reduces the risk for aspiration. B. Proper elevation of the head of the bed promotes the patient's digestion. C. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. D. Nutrients are absorbed more efficiently when the head of the bed is elevated.

A. Elevating the head of the bed reduces the risk for aspiration.

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? A. Examine each naris for patency and skin breakdown. B. Place the patient in the high-Fowler's position. C. Anesthetize the throat. D. Have the patient take a few sips of water.

A. Examine each naris for patency and skin breakdown. Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort. Although the high-Fowler's position is recommended for insertion of a nasogastric tube, the position itself will not reduce discomfort. Anesthetizing the throat would hinder the patient's ability to swallow safely during insertion of the nasogastric tube. Sipping water will not reduce the patient's discomfort.

To which position would the nurse assist the patient who is experiencing difficulty with breathing? A. Fowler's position B. 30-degree lateral position C. Sims' position D. Prone position

A. Fowler's position *In the Fowler's position the head of the bed is elevated and maximal breathing space in the thoracic cavity is promoted. Fowler's is the position of choice for a patient having breathing difficulties.

Which action might the nurse take when drawing up medication from an ampule? A. Hold the ampule upside down while inserting the filter needle. B. Inject air into the ampule before withdrawing the medication. C. Hold the ampule horizontally while inserting the filter needle. D. Expel air bubbles from the syringe while the filter needle is still inside the ampule.

A. Hold the ampule upside down while inserting the filter needle. *The ampule is either held upside down or placed on a flat surface to withdraw medication.

How can the nurse prevent negative pressure from building up in the vial when preparing an injection? A. Inject a volume of air into the vial equivalent to the volume of medication to be withdrawn. B. Insert the needle through the center of the rubber seal. C. Keep the tip of the needle below the level of fluid in the vial. D. Tap the barrel of the syringe to dislodge air bubbles.

A. Inject a volume of air into the vial equivalent to the volume of medication to be withdrawn.

What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? A. Injecting the medication at the prescribed rate B. Observing the insertion site after giving the medication C. Instructing the patient about side effects to report to the nurse D. Using an alcohol swab to wipe the insertion port on the primary tubing

A. Injecting the medication at the prescribed rate *Injecting the medication at the prescribed rate is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus, since injecting the medication faster than recommended may result in injury or death.

Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? A. To provide the correct amount of oxygen to the patient B. To ensure the therapeutic effects of oxygen therapy C. To prevent any adverse reaction to the prescribed oxygen therapy D. To minimize the risk of combustion during oxygen delivery

A. To provide the correct amount of oxygen to the patient

A patient with type 2 diabetes mellitus tells the nurse that he has been testing his own blood glucose level six times per day for the past 3 years. What is the most appropriate action for the nurse to take? A. Observe the patient's testing technique for accuracy. B. Advise the patient that he is not permitted to perform his own blood glucose testing. C. Check with the patient's health care provider concerning the patient's self-testing. D. Explain to the patient that a nurse must complete blood glucose testing.

A. Observe the patient's testing technique for accuracy.

Why would the nurse provide special instructions to nursing assistive personnel (NAP) before feeding a patient with dysphagia? A. To reduce the risk of aspirating food or fluids B. To ensure that an accurate intake measurement is reported C. To encourage the patient to eat more of the food items on the meal tray D. To ensure that the NAP knows which foods to avoid when feeding the patient

A. To reduce the risk of aspirating food or fluids

After oropharyngeal suctioning, what does the nurse do with the supplies? A. Place the Yankauer catheter in a clean, dry area. B. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. C. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. D. Place dirty gloves in the biohazard receptacle in the patient's room.

A. Place the Yankauer catheter in a clean, dry area. Placing the Yankauer catheter in a clean, dry area will protect it until it is needed again. Supplies are not disposed of in the trash, and the Yankauer tube can be used again. The supplies need not be placed in a biohazard bag.

The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in reexpanding the affected lung? A. Placing the patient in a right side-lying position B. Encouraging the patient to deep breathe and cough every hour C. Regularly assessing the patient's ability to breathe comfortably D. Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale

A. Placing the patient in a right side-lying position Placing the patient in a right side-lying position will facilitate reexpansion of the affected lung. The unaffected lung should be next to the bed, and the affected lung should be up.

What would the nurse do to remove air trapped in a syringe before withdrawing the syringe from the vial? A. Position the tip of the needle in the vial's airspace, and tap the barrel of the syringe. B. Position the tip of the needle below the fluid line, and tap the vial. C. Position the vial on a flat surface, and tap the syringe. D. Position the syringe above the vial, and tap the vial.

A. Position the tip of the needle in the vial's airspace, and tap the barrel of the syringe. *Positioning the tip of the needle in the vial's airspace and then tapping the barrel of the syringe will encourage any trapped air to move to the top of the syringe, where it can be expelled into the vial airspace.

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? A. Positioning the patient in a high-Fowler's position B. Assessing the patient's abdomen for bowel sounds C. Determining any history of unexplained nosebleeds D. Educating the patient about the need for the intervention

A. Positioning the patient in a high-Fowler's position Positioning the patient is within NAP scope of practice. NAP are not permitted to assess bowel sounds. It is not within NAP scope of practice to determine any portion of the patient's medical history. Patient education may not be delegated to NAP.

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. B. Use a distraction technique to divert the patient's attention during the procedure. C. Position the patient comfortably before the intervention. D. Thoroughly explain the procedure to the patient.

A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.

The nurse has provided a patient with a PRN oral analgesic that may be repeated as needed every 6 to 8 hours. What is the most appropriate follow-up action to ensure appropriate pain management? A. Reassess the patient's pain in 30 to 40 minutes. B. Document the patient's request for pain medication. C. Administer the pain medication again in 6 hours. D. Include the patient's pain history in the end-of-shift nursing report.

A. Reassess the patient's pain in 30 to 40 minutes.

What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? A. Regularly measure and trend the patient's pulse oximetry (SpO2) values. B. Evaluate venous blood levels every morning. C. Monitor the patient's arterial blood gas (ABG) levels hourly. D. Assess the patient for compliance with the prescribed therapy.

A. Regularly measure and trend the patient's pulse oximetry (SpO2) values.

Which nursing action is appropriate when feeding gastric residual is 50 mL? A. Return it to the stomach via the feeding tube. B. Dispose of the residual contents down the commode. C. Discard the stomach contents as a liquid biohazard. D. Return half of the volume to the stomach, and discard the rest.

A. Return it to the stomach via the feeding tube. If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube. This small amount of gastric aspirate can be returned to the stomach.

The nurse has just helped a patient into the bathtub. Before leaving the bathroom, what would the nurse do to help ensure the patient's safety? A. Show him how to use the call signal. B. Place an "Occupied" sign on the door. C. Check the cleanliness of the room. D. Remove unneeded supplies from the bathroom.

A. Show him how to use the call signal.

In which position will the nurse place the patient to move him or her up in bed? A. Supine with the head of the bed flat B. Sitting in the bed C. Supine with the head of the bed at a 30-degree angle D. Prone with the head of the bed flat

A. Supine with the head of the bed flat

How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing? A. Use aseptic technique throughout the process. B. Pull the tape toward the insertion site. C. Remove both the gauze dressing and the tape one layer at a time. D. Explain the process to the patient.

A. Use aseptic technique throughout the process.

Which site is most commonly used for intramuscular injections? A. Ventrogluteal B. Abdominal C. Deltoid D. Dorsogluteal

A. Ventrogluteal

Bradypnea

Abnormally slow breathing. A respiratory rate that is too slow. The normal rate of respirations (breaths per minute) depends on a number of factors, including the age of the individual and the degree of exertion *Less than 12 breaths per minute

Flatulence

Accumulation of gas in the intestines causing the walls to stretch

Standard precautions are used:

Across the board with everyone *Localized infections treated with standard precautions

Retention

Acute retention: Suddenly unable to void when bladder is adequately full or overfull Chronic retention: Bladder does not empty completely during voiding, and urine is retained in the bladder

Buccal

Administration of a medication by the buccal route involves placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves. Teach patients to alternate cheeks with each subsequent dose to avoid mucosal irritation. Warn patients not to chew or swallow the medication or to take any liquids with it. A buccal medication acts locally on the mucosa or systemically as it is swallowed in a person's saliva.

Advantages and Disadvantages of Rectal Temperature Measurement Sites

Advantages: - Argued to be more reliable when oral temperature is difficult or impossible to obtain Disadvantages: - Lags behind core temperature during rapid temperature changes - Not for patients with diarrhea, rectal disorders, or bleeding tendencies or those who had rectal surgery - Requires positioning and is often source of patient embarrassment and anxiety - Risk of body fluid exposure and injury to rectal lining - Requires lubrication - Not for routine vital signs in newborns - Readings influenced by impacted stool

Advantages and Disadvantages of Tympanic Membrane Temperature Measurement Sites

Advantages: - Easily accessible site - Minimal patient repositioning required - Obtained without disturbing, waking, or repositioning patients - Used for patients with tachypnea without affecting breathing - Sensitive to core temperature changes - Very rapid measurement (2 to 5 seconds) - Unaffected by oral intake of food or fluids or smoking - Used in newborns to reduce infant handling and heat loss - Not influenced by environmental temperatures Disadvantages: - More variability of measurement than with other core temperature devices - Requires removal of hearing aids before measurement - Requires disposable sensor cover with only one size available - Otitis media and cerumen impaction distorts readings - Not used in patients who have had surgery of the ear or tympanic membrane - Does not accurately measure core temperature changes during and after exercise - Does not obtain continuous measurement - Affected by ambient temperature devices such as incubators, radiant warmers, and facial fans - When used in neonates, infants, and children under 3 years old, use care to position device correctly because anatomy of ear canal makes it difficult to position - Inaccuracies reported caused by incorrect positioning of handheld unit

Advantages and Disadvantages of Skin Temperature Measurement Sites

Advantages: - Inexpensive - Provides continuous reading - Safe and noninvasive - Used for neonates Disadvantages: - Measurement lags behind other sites during temperature changes, especially during hyperthermia - Adhesion impaired by diaphoresis or sweat - Reading affected by environmental temperature - Cannot be used for patients with allergy to adhesives

Advantages and Disadvantages of Axillary Temperature Measurement Sites

Advantages: - Safe and inexpensive - Reliable in stable term and preterm infants Disadvantages: - Long measurement time - Requires continuous positioning - Measurement lags behind core temperature during rapid temperature changes - Not recommended for detecting fever - Requires exposure of thorax that can result in temperature loss, especially in newborns - Affected by exposure to environment, including time to place the thermometer - Underestimates core temperature

Availability of Veins

Although veins are found in the same location in most people with minor variations, certain situations might make it more difficult to find them such as: - Body fat - Burns and scarred skin - Edema

What is The Joint Commission (TJC)?

An independent, not-for-profit group in the United States that accredits hospitals and other health care-related agencies.

Describe the use of the following with rationale(s): Ankle-foot orthotic (AFO)

Ankle-foot orthotic (AFO) devices also help maintain dorsiflexion. *Patients who wear positioning boots or AFOs need to have these removed periodically (e.g., 2 hours on, 2 hours off).

Anaphylactic

Anxiety, urticaria, dyspnea, wheezing progressing to cyanosis, severe hypotension, circulatory shock, possible cardiac arrest Causes: - Antibodies to donor plasma, especially anti-IgA

Abuse

Anything offensive, harmful, or injurious to an individual that can pose a direct safety threat

Describe the use of the following with rationale(s): Positioning boots

Apply positioning boots to prevent footdrop by maintaining the feet in dorsiflexion.

How do you assess for orthostatic hypotension?

Assess for orthostatic hypotension during measurements of vital signs by obtaining BP and pulse in sequence with the patient supine, sitting, and standing. Obtain BP readings within 3 minutes after the patient changes position. In most cases orthostatic hypotension is detected within a minute of standing.

What is the first step in the nursing process?

Assessment - First thing collected is history: from patient is subjective, also medication history collected - After gathering patients history, we gather objective data (Labs, vital signs, and your actual assessment of patient)

Nocturia

Awakened from sleep because of the urge to void

The nurse is instructing a patient who is to receive both a bronchodilator and a steroid medication delivered by means of a metered-dose inhaler (MDI). Which instruction is necessary for the safe administration of both agents? A. "Make sure to use the steroid medication before the bronchodilator." B. "Make sure to use the bronchodilator before the steroid medication." C. "Rinse your mouth with warm water before using the MDI to administer either medication." D. "Make sure you wait at least 30 seconds between administering the bronchodilator and administering the steroid medication."

B. "Make sure to use the bronchodilator before the steroid medication." *Using the bronchodilator first opens the airways before the steroid is administered, enhancing the effects of both.

In providing foot care, the nurse would soak the feet and hands of which patient? A. A 30-year-old man with type 1 diabetes. B. An 86-year-old woman with generalized weakness. C. A 56-year-old patient with vascular insufficiency who was bathed the day before. D. A 56-year-old patient with vascular insufficiency who was not bathed the day before.

B. An 86-year-old woman with generalized weakness.

For which situation would the procedure of glucose testing be interrupted? A. The reagent strip code matches the code on the vial. B. An unused lancet is not available. C. The glucose meter beeps. D. A drop of blood forms on the patient's skin after it is punctured.

B. An unused lancet is not available.

Which action by the nurse would reduce his or her exposure to bloodborne pathogens while administering fluids to a patient by mini-infusion pump? A. Cleaning the injection port with an antiseptic swab B. Applying clean gloves C. Recapping the end of the mini-infusion tubing after use D. Performing hand hygiene prior to administration

B. Applying clean gloves

When preparing to move a patient in bed, what will the nurse do first? A. Assemble adequate help to move the patient. B. Assess the patient's ability to help with moving. C. Determine the patient's weight. D. Decide on the most effective means of moving the patient.

B. Assess the patient's ability to help with moving. *Assessing the patient's ability to help is the first thing the nurse must do, since the answer determines how much help is needed with the move.

As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority? A. Provide all the necessary supplies and linen for this task. B. Assess the patient's ability to perform proper perineal care. C. Ensure that the patient has privacy while performing perineal care. D. Document any complaints of irritation or pain in the perineal area.

B. Assess the patient's ability to perform proper perineal care.

Which action would the nurse carry out first when performing a blood glucose test on a patient with type 1 diabetes mellitus? A. Apply clean gloves to minimize the risk for contamination. B. Assess the patient's skin for possible puncture sites. C. Ask the patient to wash his or her hands and forearms with warm, soapy water. D. Determine the patient's preferred puncture site.

B. Assess the patient's skin for possible puncture sites.

When irrigating a wound, how would the nurse know the right amount of pressure to apply? A. Calculate the wound size. B. Follow the general rule of keeping the pressure between 4 and 15 psi. C. Keep the pressure strong enough to cause moderate pain. D. Gentle enough that is does not create a splash off of the wound.

B. Follow the general rule of keeping the pressure between 4 and 15 psi.

Chlorhexidine gluconate (CHG) bath:

This antimicrobial bath wipe is used to decrease the frequency of hospital-acquired infections on skin, invasive lines, and catheters.

Before teaching a patient postsurgical exercises, the nurse premedicates the patient for pain. What benefit does this have specific to the patient's learning? A. Reduced pain B. Improved focus C. Decreased relaxation D. Decreased irritability

B. Improved focus

Which wound would be allowed to heal by secondary intention? A. Cleft lip repair B. Infected hysterectomy incision C. Exploratory laparoscopy incision D. Facial laceration caused by a pocket knife

B. Infected hysterectomy incision *The infected hysterectomy incision would heal by secondary intention because it is an infected surgical wound. The cleft lip repair and the exploratory laparoscopy incision would heal by primary intention because they were created during a surgical procedure. The facial laceration caused by a pocket knife would heal by primary intention, since there is no tissue loss.

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? A. Complete the suctioning process in 20 seconds or less. B. Keep the oxygen mask near the patient's face during the suctioning procedure. C. Encourage the patient to take several deep breaths before suctioning begins. D. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

B. Keep the oxygen mask near the patient's face during the suctioning procedure. Keeping the oxygen mask near the patient's face during the intervention ensures that oxygen therapy will not be interrupted. Although the intervention should be completed in a timely manner, doing so in less than 20 seconds is not a priority. Encouraging the patient to breathe deeply before the suctioning is not a specific intervention related to oropharyngeal suctioning. The flow rate can be increased before suctioning, but doing so is not a priority intervention.

When placing an intraocular disk, the nurse recognizes that it is in the correct position by assessing what? A. Visibility of the disk over the cornea B. Lack of visibility of the disk as it is placed under the lower eyelid C. Lack of visibility as it is placed under the upper eyelid D. Visibility of a small portion of the disk extending slightly above the lower eyelid

B. Lack of visibility of the disk as it is placed under the lower eyelid

What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? A. Remove the tubing from the primary line Y-site port, and cap the end. B. Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. C. Place an unopened secondary setup at the bedside, and discard the used one. D. Change both the primary and secondary tubing upon terminating the piggyback infusion.

B. Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. *Leaving the piggyback tubing and bag attached will help maintain tube sterility while conserving supplies and nursing time.

Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? A. Massage the site after administration. B. Make sure the volume of the medication is less than 2 mL. C. Administer the injection at a 45- to 90-degree angle. D. Wear clean gloves while administering the injection.

B. Make sure the volume of the medication is less than 2 mL

What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? A. Assess the patient's level of consciousness every 4 hours. B. Monitor the patient's pulse oximetry readings. C. Verify the pressure settings for both inspiratory and expiratory pressure. D. Evaluate daily arterial blood gases (ABGs)

B. Monitor the patient's pulse oximetry readings.

Which task might the nurse delegate to nursing assistive personnel (NAP) caring for a patient receiving IV medication via mini-infusion pump? A. Assessing the IV site frequently for signs of infiltration B. Notifying the nurse if the pump alarm sounds C. Informing the physician that the patient is allergic to the prescribed medication D. Ensuring that the medications being delivered intravenously are compatible

B. Notifying the nurse if the pump alarm sounds

Before discharge, the nurse shows a patient how to use a dry powder inhaler (DPI). What should the nurse now assess? A. Patient's understanding of the purpose of the medication B. Patient's ability to handle, manipulate, and activate the DPI C. Adequacy of the patient's planned daily medication schedule D. Patient's awareness of the signs of an allergic reaction to the medication

B. Patient's ability to handle, manipulate, and activate the DPI *The nurse would assess the patient's ability to handle, manipulate, and activate the DPI, because inability to do so could affect proper delivery of the medication.

When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? A. Apply therapeutic boots to the feet. B. Place sandbags along the legs. C. Place a small pillow at the lumbar region of the back. D. Place a pillow under the calves.

B. Place sandbags along the legs. *Placing sandbags along the legs will prevent the hips from rolling outward.

Which discharge instruction would help to ensure that the patient achieves maximum therapeutic delivery of the medication when using a metered-dose inhaler (MDI)? A. Make sure to report any adverse effects after using your inhaler. B. Prime the inhaler if it is new or has not been used for several days. C. Hold your breath for 60 seconds after the medication is delivered. D. Use the inhaler while sitting up in a chair at 90-degree angle.

B. Prime the inhaler if it is new or has not been used for several days. *Priming the inhaler will help to ensure effective dispersion of the medication.

What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed? A. Assessing the patient for abdominal distention B. Providing the patient with mouth care C. Documenting tube removal D. Checking for bowel sounds

B. Providing the patient with mouth care

The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move? A. Hold the slide board stationary. B. Pull the draw sheet. C. Hold the patient's head stationary. D. Lock the brakes on the stretcher.

B. Pull the draw sheet. *The nurse, standing alone, will hold the slide board in place as the two assistants pull the draw sheet.

What would the nurse use to irrigate a patient's nasogastric tube after providing medications? A. Coffee B. Purified water C. Tea D. Apple juice

B. Purified water Coffee, tea, and apple juice increase the likelihood of tube clogging.

A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed? A. Help the patient put on skid-resistant footwear. B. Raise the head of the bed 30 degrees. C. Place the transfer belt over the patient's clothing. D. Position the chair so that the patient will move toward his or her stronger side.

B. Raise the head of the bed 30 degrees. *The nurse would raise the head of the bed 30 degrees right before moving the patient to the side of the bed. Footwear and the transfer belt would not be applied at this point in the process. The wheelchair would already be in position at this point in the process.

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? A. Complete the catheter insertion in 5 seconds or less. B. Remove the catheter. C. Encourage the patient to take several deep breaths to minimize the nausea. D. Stop advancing the catheter, and allow the patient to rest for several minutes.

B. Remove the catheter. Gagging and nausea indicate that the catheter has probably entered the esophagus and must be removed. Attempting to complete the insertion could increase the gagging and nausea.

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound? A. Assessing the site for signs of redness or swelling B. Reporting the presence of wound odor C. Removing a soiled outer dressing D. Opening sterile dressings during the dressing change

B. Reporting the presence of wound odor

What would the nurse do first when preparing to begin oxygen therapy for a patient? A. Educate the NAP about the oxygen orders. B. Review the medical prescription for delivery method and flow rate. C. Place a "No Smoking" sign outside of the hospital room. D. Ensure that suction equipment is present in the room.

B. Review the medical prescription for delivery method and flow rate.

Which action by the nurse ensures patient safety when administering an intramuscular injection? A. Putting on clean gloves before administration B. Rotating injection sites C. Aspirating for blood return when administering a vaccine D. Injecting the medication quickly

B. Rotating injection sites *Rotating injection sites is important in order to prevent hypertrophy of tissue.

What is the most important nursing intervention to ensure the patient's safety when initiating infusion of an analgesic by mini-infusion pump? A. Checking the flow rate of the primary infusion B. Staying with the patient during the first few minutes of the infusion C. Explaining the purpose of the medication to the patient D. Documenting the patient's expected response to the analgesic

B. Staying with the patient during the first few minutes of the infusion

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury? A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment. C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, efficient manner.

B. Use appropriate personal protective equipment.

After instructing a patient in the self-administration of antibiotic eye drops, what is the nurse's highest priority assessment? A. The patient's understanding of the medication's purpose B. The patient's hand grasp, strength, coordination, and ability to manipulate the applicator C. The patient's comprehension of the dosage instructions provided with the medication D. The patient's ability to recognize the signs of an allergic reaction to the medication

B. The patient's hand grasp, strength, coordination, and ability to manipulate the applicator

What is the best way for the nurse to minimize the risk of contaminating the patient's eye during the instillation of eye drops? A. Encourage the patient to self-apply the medication. B. Wear gloves during the entire application process. C. Introduce the medication onto the inner canthus of the eye. D. Perform effective hand hygiene before and after the instillation.

B. Wear gloves during the entire application process.

When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of sterile water through the catheter? A. To moisten the exterior of the plastic catheter B. To ensure that the catheter's suction is functioning properly C. To minimize friction as the catheter moves within the oral cavity D. To avoid startling the patient with the sound created by the suction

B. To ensure that the catheter's suction is functioning properly

Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? A. To maximize a sense of well-being B. To minimize postoperative complications C. To identify cultural factors that reflect the patient's perception of pain D. To evaluate the patient's ability to participate in postoperative activities

B. To minimize postoperative complications

When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? A. To reduce the risk of a fall while the side rails are down B. To reduce the risk of contracture C. To control pain D. To cushion the legs

B. To reduce the risk of contracture *A trochanter roll is placed alongside the patient's legs to prevent external rotation of the hips, which contributes to contracture.

Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? A. Hold your breath when turning. B. Use a pillow to splint the incision. C. Take pain medication 30 minutes before turning. D. Keep both legs straight when turning.

B. Use a pillow to splint the incision.

What would the nurse do to assess a patient's risk for embolus when removing a venous access device? A. Inspect the site for redness. B. Visualize the tip of the IV device. C. Palpate the site for possible edema. D. Ask the patient to rate any pain at the site.

B. Visualize the tip of the IV device. *Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form.

The nurse is preparing to give a patient a bath using a disposable bath-in-a-bag product. What should the nurse do first? A. Remove the patient's gown. B. Warm the product in the microwave. C. Obtain a washbasin. D. Gather towels and washcloths.

B. Warm the product in the microwave.

The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care? A. Wear sterile gloves. B. Wear clean gloves. C. Wear an isolation gown. D. Use hot water.

B. Wear clean gloves.

Which action would the nurse encourage an older adult with foot problems to take at home? A. Apply oval pads to treat corns. B. Wear socks made of natural fibers. C. Carefully shave off calluses with a razor blade. D. If a bandage is needed, apply gauze squares with adhesive tape.

B. Wear socks made of natural fibers. *Natural fibers, such as cotton, absorb perspiration and "breathe." Use of oval pads for corns can exert pressure on toes, thereby decreasing circulation to surrounding tissues. Patients should seek professional treatment for corns. A patient should never trim corns or calluses with a razor blade or scissors. Doing so puts the patient at risk of cutting the skin, which can lead to infection. The thin, delicate skin of an older adult is prone to tearing when adhesive tape is removed.

Why does hypotension occur?

Because of the dilation of the arteries in the vascular bed, the loss of a substantial amount of blood volume (e.g., hemorrhage) or the failure of the heart muscle to pump adequately (e.g., myocardial infarction)

How often should you turn and reposition a patient? Rationale.

Before moving you always have to assess the patient: - The major risk is pressure ulcers * One to two hours is standard practice for preventing ulcers * Some patients require surface devices for relieving pressure - Activity level - Perceptual ability - Treatment protocols - Daily routines

How can you assess for risk of developing a pressure ulcers?

Braden scale

When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next? A. Nothing, since this is an expected pH value B. Advance the tube C. Anticipate a chest x-ray D. Pull back on the tube

C. Anticipate a chest x-ray Normal gastric pH is 5 or less. A pH greater than 7 could mean that the tube is in the small intestine or lung.

Which instruction to nursing assistive personnel (NAP) reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving intravenous (IV) fluids by gravity drip? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 mL." D. "Tell the patient to notify me if the IV site is painful, swollen, or red."

C. "Let me know when you notice that the IV bag contains less than 100 mL."

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a nasogastric (NG) tube? A. "Remember to aspirate 5 mL to 10 mL of stomach contents before flushing the tube." B. "Let me know if the patient complains of anything related to the NG tube's placement." C. "Tell me if you see any vomit in the patient's mouth during oral care." D. "Please see if the NG tubing has advanced at all."

C. "Tell me if you see any vomit in the patient's mouth during oral care." Responsibility for this aspect of care related to NG tube management may be delegated to NAP. Responsibility for aspirating 5 mL to 10 mL of stomach contents before flushing the tube and checking to see if the NG tubing has advanced are not aspects of NG tube management that can be delegated to NAP. NAP would not be aware of what an NG-type complaint is.

Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? A. 20-gauge, ½-inch B. 22-gauge, 1-inch C. 25-gauge, ⅜-inch D. 27-gauge, 1-inch

C. 25-gauge, ⅜-inch

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? A. Patient complains of discomfort during the procedure. B. Patient has a severe bout of nonproductive coughing and complains of sore throat. C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. D. Patient's pulse rate increases by 10 bpm.

C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. This decline in peripheral blood oxygen saturation must be reported. It represents a decline in the patient's condition following a procedure that should have improved his or her SpO2 reading. Discomfort need not be reported. Symptoms of coughing and sore throat do not require immediate reporting. This change in heart rate is anticipated with the procedure. Taken by itself, it does not require reporting

When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? A. After performing hand hygiene at the start of the procedure B. Before removing the inner dressing C. After removing the original dressing materials and performing hand hygiene a second time D. Just before cleansing the wound with sterile water

C. After removing the original dressing materials and performing hand hygiene a second time

How would the nurse safely apply an enzyme debridement ointment? A. Daub ointment on dead tissue at the wound edges. B. Put ointment on a tongue blade, and gently spread it on the center of the wound. C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. D. Apply a gauze dressing to ensure contact with the ointment.

C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve? A. After the patient crosses the arms over the chest B. After the patient's eyeglasses are removed C. As soon as the patient has been placed in the chair D. When the nurse removes the straps

C. As soon as the patient has been placed in the chair

A patient with a history of nighttime confusion is to receive several oral medications at bedtime. What is the best way for the nurse to ensure that the patient has swallowed the medication? A. Administer each tablet individually. B. Observe the patient closely as he swallows the tablets. C. Ask the patient to open his mouth after swallowing each tablet. D. Ask the patient to swallow a full glass of water with the tablets.

C. Ask the patient to open his mouth after swallowing each tablet.

A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? A. A minimum of two B. None, since the device does all the lifting during the move C. At least three D. The nurse can carry out this move without assistance

C. At least three *Since a friction-reducing device will be used and the client weighs more than 157 lbs., a minimum of three to four people are needed to move this patient safely.

How can the nurse promote infection control while providing perineal care for a female patient who has a catheter? A. By avoiding the application of tension on the catheter. B. By patting, not rubbing, the skin dry after thoroughly rinsing it. C. By cleansing the patient's labia from the pubic area toward the rectum. D. By using warm water to cleanse the patient's entire perineal area.

C. By cleansing the patient's labia from the pubic area toward the rectum.

What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube? A. Listen to bowel sounds. B. Listen to lung sounds. C. Check NG tube placement. D. Turn the patient onto his or her left side.

C. Check NG tube placement.

How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? A. Elevate the head of the patient's bed to at least 30 degrees. B. Use an intravenous fluid infusion set. C. Check the gastric residual volume. D. Monitor the amount of intake the patient tolerates in an 8-hour period.

C. Check the gastric residual volume.

When preparing an intramuscular injection, what can the nurse do to reduce the patient's risk for infection? A. Wear clean gloves. B. Use a 3-mL syringe. C. Clean the injection site with an alcohol swab. D. Massage the injection site.

C. Clean the injection site with an alcohol swab.

What can the nurse do to minimize the discomfort of a subcutaneous injection? A. Inject the medication rapidly. B. Massage the injection site. C. Cover the injection site with gauze pad after withdrawing the needle. D. Inject the medication without pinching the skin.

C. Cover the injection site with gauze pad after withdrawing the needle.

A patient with left-sided muscle weakness is prescribed a bath every other day. Which precaution would help the nurse reduce this patient's risk of falling? A. Maintain the water temperature at 104°F. B. Allow the patient to remain in the bath for 45 minutes. C. Decline the patient's request to add scented oil to the bathwater. D. Discuss the patient's level of fatigue after the bath.

C. Decline the patient's request to add scented oil to the bathwater.

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? A. Encourage the patient to take several deep breaths. B. Interrupt suction to the catheter for at least 10 seconds. C. Discontinue suctioning by removing the suction catheter. D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.

C. Discontinue suctioning by removing the suction catheter. A drop in pulse of 20 bpm or more necessitates discontinuation of suctioning and removal of the catheter. Deep breathing will not adequately address the patient's response. Pausing the suctioning briefly will not adequately address the patient's response. Taking an oximetry reading will not address the patient's response.

The nurse is helping a patient get out of a bathtub, and the patient appears to be unsteady on her feet. What should the nurse do to help ensure the patient's safety? A. Drape a bath towel over the patient's shoulders. B. Demonstrate how to use the call light for assistance. C. Drain the bathtub before the patient gets out. D. Apply lotion to the patient's freshly dried skin.

C. Drain the bathtub before the patient gets out.

What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? A. Encourage oral fluids. B. Restrict fluids. C. Ensure that humidification is present. D. Measure blood pressure every hour.

C. Ensure that humidification is present. If the oxygen flow rate is 4 L/min or higher, add humidification and verify that water is bubbling in the humidifier. Fluids need not be encouraged in the patient receiving 4 L/min oxygen by nasal cannula. Fluids need not be restricted in the patient receiving 4 L/min oxygen by nasal cannula. Blood pressure need not be measured every hour in a patient receiving 4 L/min oxygen by nasal cannula.

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? A. Stand with the knees locked. B. Stand with the feet together. C. Flex the hips and knees. D. Shift the body weight from the back leg to the front leg.

C. Flex the hips and knees.

How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic? A. Use the injection port closest to the patient. B. Assess the IV insertion site for signs of infiltration. C. Follow aseptic technique during the entire process. D. Instruct the patient to report any adverse medication reactions.

C. Follow aseptic technique during the entire process.

The wound bed of a patient's pressure injury is red. What does this finding indicate to the nurse? A. Necrotic tissue B. Presence of slough C. Granulation tissue D. Development of an infection

C. Granulation tissue *Granulation tissue is red. Necrotic tissue is black. Slough tissue is yellow or gray. An early infection shows up as yellow.

When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? A. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. B. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.

C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. Inspecting electrical equipment would take priority among the other interventions in providing environmental safety. Placing appropriate signage to alert others to the presence of oxygen and instructing the NAP to immediately correct or report safety hazards do not take priority regarding environmental safety. Ensuring the patient receives the prescribed amount of oxygen does not pertain to environmental safety

What can the nurse do to keep the patient from becoming chilled while receiving a bath with a disposable bath-in-a-bag product? A. Dry each body part with a warmed towel after washing. B. Wash the product off of the skin with a warm, moistened washcloth. C. Lightly cover the patient with a bath towel. D. Keep the patient's gown on for the bath.

C. Lightly cover the patient with a bath towel. *Covering the patient with a bath towel will help prevent chilling as the product dries. After using the disposable bath product, the skin is allowed to air dry for 30 seconds. The disposable bath-in-a-bag product is not washed off of the skin. The patient's gown should be removed for the bath.

The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first? A. Cross the patient's arms over his or her chest. B. Lower the side rails of the bed. C. Make sure the bed brakes are locked. D. Fanfold the draw sheet.

C. Make sure the bed brakes are locked.

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety? A. Use the call light to ask someone else to bring a washcloth. B. Raise all four side rails on the patient's bed. C. Make sure the call light is within the patient's reach. D. Raise the bed to its highest position.

C. Make sure the call light is within the patient's reach.

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? A. Ask another nurse to attempt the insertion. B. Document the attempts in the patient's medical record. C. Notify the physician that the attempts were unsuccessful. D. Allow the patient to rest for 30 minutes before resuming the process.

C. Notify the physician that the attempts were unsuccessful. The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option. Attempting to insert a tube again may harm the patient. Although documentation is necessary, it does not address the patient's need for a nasogastric tube. Delaying an attempt at inserting the nasogastric tube makes success no more likely and risks harming the patient.

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? A. Flush the tube with ginger ale. B. Use apple juice to flush the tube. C. Obtain a product designed to unclog NG tubes. D. Force-flush the system with sterile normal saline.

C. Obtain a product designed to unclog NG tubes.

When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? A. Increase the oxygen level as needed for the patient's comfort. B. Store extra oxygen cylinders horizontally. C. Place a "No Smoking" sign at the entrance to the house. D. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.

C. Place a "No Smoking" sign at the entrance to the house. "No Smoking" signs should be placed throughout the house as well as at the entrance. Oxygen may not be increased based on the patient's comfort. Extra cylinders should be stored vertically. Keep oxygen at least 10 feet (about 3 meters) away from anything that could generate a spark

The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side? A. Place a small pillow under the shoulder. B. Use the affected arm as a guide during rolling. C. Place a pillow on the abdomen. D. Place rolled bath blankets along the dependent leg.

C. Place a pillow on the abdomen.

How might the nurse safely administer an extended-release capsule to a patient with dysphagia? A. Encourage the patient to drink plenty of water when swallowing the capsule. B. Open the capsule, and place the contents into 90 mL (3 fl. oz.) of juice. C. Place the capsule in a spoonful of the patient's applesauce. D. Save the capsule to be administered last.

C. Place the capsule in a spoonful of the patient's applesauce. *Placing the capsule in a spoonful of the patient's applesauce helps lubricate the capsule, thereby facilitating the patient's ability to swallow it.

Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness? A. Raising the patient quickly into a sitting position after completing a bed shampoo. B. Getting water into the patient's ears during the rinsing phase of the shampoo. C. Placing the neck in a hyperextended position during the shampoo process. D. Having the entire shampooing process last longer than 15 minutes.

C. Placing the neck in a hyperextended position during the shampoo process. *Placing the neck in a hyperextended position during the shampoo process can trigger dizziness, particularly in a patient with a history of dizziness. Raising any patient quickly into a sitting position is not a good idea, but doing so is not of greater concern for a bed-bound patient with dizziness. Getting water into any patient's ears should be avoided, but doing so is not of greater concern for a bed-bound patient with dizziness. The length of the shampooing process does not pertain to dizziness.

What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? A. Recalculate the present drip factor for accuracy. B. Terminate the fluid, and prepare to hang a new bag of formula. C. Plan to check the feeding for completion within the next 3 hours. D. Check with the pharmacy to see if the formula has been hanging too long.

C. Plan to check the feeding for completion within the next 3 hours.

How might the nurse minimize the patient's anxiety when removing a nasogastric tube? A. Administer a mild sedative prescribed by the patient's health care provider. B. Ask the patient's caregiver to emotionally support the patient during the removal. C. Provide reassurance of what will happen during the procedure and talk the patient through the process. D. Instruct the patient to take deep, calming breaths while revisiting a pleasant memory.

C. Provide reassurance of what will happen during the procedure and talk the patient through the process.

What is the most effective way of preventing aspiration? A. Observe the patient closely for coughing, gagging, choking, and voice alteration. B. Monitor oxygen saturation with pulse oximetry. C. Put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist (SLP). D. Watch for subtle signs that aspiration may have occurred, such as lack of speech, depressed alertness, wet quality to the voice, difficulty controlling secretions, and absence of a gag reflex.

C. Put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist (SLP). All of the choices listed are steps that reduce the risk of aspiration. The most important precaution to prevent aspiration, however, is to put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a SLP.

After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next? A. Lock the wheels on the stretcher. B. Cover the patient with a blanket. C. Raise the side rails on the stretcher. D. Unlock the wheels of the bed.

C. Raise the side rails on the stretcher. *The nurse will raise the side rails after adjusting the head of the stretcher. The wheels of the stretcher will have been locked before moving the patient from the bed to the stretcher. Covering the patient with a blanket will occur after the side rails are raised on the stretcher.

The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up? A. Assisting the patient into the supine position in bed. B. Cleansing the tip of the penis with a circular motion, starting at the meatus. C. Reserving the cleansing of the tip of the penis as the final step in perineal care. D. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin.

C. Reserving the cleansing of the tip of the penis as the final step in perineal care. *Proper cleansing requires that the tip of the penis be cleansed first, to minimize the introduction of pathogens to the meatus. The nurse's observation of improper technique requires follow-up teaching.

In which site would it be inappropriate to administer an intradermal injection? A. Lower abdomen of an obese patient B. Upper back of a patient who is on bed rest C. Right deltoid of a high school softball pitcher D. Left forearm of a patient with right-sided weakness

C. Right deltoid of a high school softball pitcher *The deltoid area is not an acceptable intradermal injection site for any patient. If the forearm and back cannot be used, it is acceptable to use sites routinely used for subcutaneous injections.

The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient's eyes? A. Remove eye crusts with soapy water. B. Avoid closing the patient's eyes. C. Use eye patches or shields taped in place. D. Tape the patient's eyelids closed.

C. Use eye patches or shields taped in place. *An eye shield or patch should be placed over each eye and taped in place.

How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? A. Encircle the arm with tape. B. Secure the tubing and catheter hub with tape. C. Secure the tubing in two different locations on the arm. D. Label the dressing with the date and time of application.

C. Secure the tubing in two different locations on the arm.

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? A. Prone B. Side-lying C. Supine D. Sims

C. Supine

How can the nurse determine that the needle tip for an intradermal injection is in the dermis? A. A bleb the size of a mosquito bite will appear. B. The needle will enter at a 5- to 15-degree angle. C. The bulge of the needle tip will be visible through the skin. D. The needle will penetrate through the epidermis to a depth of about ⅛ inch.

C. The bulge of the needle tip will be visible through the skin.

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)? A. The patient prefers that the nurse provide the care. B. NAP are not trained to perform foot care. C. The patient's elevated risk of infection makes it unsafe for NAP to perform the care. D. The patient's condition requires that he remain on bed rest.

C. The patient's elevated risk of infection makes it unsafe for NAP to perform the care.

What is the primary reason the nurse encourages the patient to participate in hair care? A. To free up the staff's time for patient care B. To make sure the care is performed according to the patient's preferences C. To encourage the patient's sense of independence D. To allow the nurse to evaluate the patient's ability to manipulate objects

C. To encourage the patient's sense of independence

What is the purpose of splinting the abdomen with a small pillow during controlled coughing? A. To minimize chest discomfort caused by the coughing B. To expand lung capacity during the inspiratory phase of the cough C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough D. To focus the patient's attention on the abdominal muscles used during the cough

C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough

When preparing an injection from an ampule, what will the nurse do if liquid is trapped in the neck of the ampule? A. Check the medication cabinet for an extra ampule of the medication. B. Notify the pharmacy that an additional ampule of medication will be needed. C. Use quick, light finger taps on the top of the ampule to move the liquid. D. Shake the medication out of the neck of the ampule.

C. Use quick, light finger taps on the top of the ampule to move the liquid.

Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? A. Using microdrip tubing for the infusion B. Using macrodrip tubing for the infusion C. Using a volume-control device for the infusion D. Not infusing more than 25 mL/hour of IV fluids

C. Using a volume-control device for the infusion

A postoperative patient is breathing rapidly. You should immediately: A. Call the physician B. Count the respirations C. Assess the oxygen saturation D. Ask the patient if he feels uncomfortable.

C. Want to have your objective information ready when you call the doctor

A nurse is preparing to withdraw medication from an open multi-dose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, what would the nurse do next? A. Apply clean gloves. B. Vigorously shake the vial. C. Wipe the rubber seal of the vial with an alcohol swab. D. Introduce air equal to the amount of medication needed.

C. Wipe the rubber seal of the vial with an alcohol swab.

What is the greatest safety concern when withdrawing medication from an ampule? A. Not wearing gloves when preparing medication B. Selecting an inappropriate needle size C. Withdrawing glass particles into the syringe D. Withdrawing bubbles into the syringe

C. Withdrawing glass particles into the syringe

What criteria determines whether your patient should be log rolled when he/she is repositioned?

CLINICAL DECISION: Supervise and assist NAP when there is a health care provider's order to logroll a patient. Patients who have suffered from spinal cord injury or are recovering from neck, back, or spinal surgery often need to keep the spinal column in straight alignment to prevent further injury.

Regulating IV Fluids

Calculating Flow Rates: Need to know : - Volume to be infused - Specific Time for Infusion

A nurse plans to provide education to the parents of school-age children, which includes the increased prevalence of __________________ as a result of children being less physically active outside of school.

Childhood obesity

Performing Bladder Irrigation: A continuous bladder irrigation (CBI) setup:

Closed catheter irrigation provides intermittent or continuous irrigation of a urinary catheter without disrupting the sterile connection between the catheter and the drainage system. CBI is an example of a continuous infusion of a sterile solution into the bladder, usually using a three-way irrigation closed system with a triple-lumen catheter. CBI is frequently used following genitourinary surgery to keep the bladder clear and free of blood clots or sediment.

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

Collect one fecal smear from three separate bowel movements.

GI system changes with immobility:

Constipation

Subcutaneous

Contains blood vessels, lymph, connective tissues ; supports the upper skin layers from stress & injury

Bag bath/travel bath:

Contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient. The bag bath offers an alternative because of the ease of use, reduced time bathing, and patient comfort.

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous (IV) site dressing? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "If the gauze dressing looks damp, replace it with a dry 4 × 4 gauze." D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."

D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."

Which statement or question best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in the instillation of eye medications? A. "Did you let the eye medication warm to room temperature?" B. "Do you think the patient is capable of instilling his own eye drops?" C. "Be sure to slightly hyperextend her neck when instilling the medication." D. "Her vision may be temporarily impaired, so please help her to the bathroom."

D. "Her vision may be temporarily impaired, so please help her to the bathroom."

The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up? A. "I will check to see if he cleans himself well." B. "I will let you know if I see any redness or drainage." C. "I will ask him if he is experiencing any pain in that area." D. "I will be sure to use hot, soapy water to be sure he's clean."

D. "I will be sure to use hot, soapy water to be sure he's clean." *This is an inappropriate statement since warm, not hot, water and mild soap should be used when cleansing the perineal area to minimize irritation.

The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up? A. "I'll ask for assistance if I need help positioning her." B. "I'll see if she's up to the care right now." C. "I'll let you know if I notice any signs of redness or discharge." D. "I'll be sure to use hot, soapy water, since she has been incontinent."

D. "I'll be sure to use hot, soapy water, since she has been incontinent." *To minimize skin irritation, warm water and mild soap should be used when cleansing the perineal area, so this statement requires the nurse's follow-up.

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt? A. "When I count to three, please rock yourself into a standing position." B. "Please hold on to my waist while I help you stand." C. "Please tell me how I can best help you get up off the bed and stand up." D. "Please push down onto the mattress with both hands and stand when I count to three."

D. "Please push down onto the mattress with both hands and stand when I count to three."

A patient has been prescribed a metered-dose inhaler (MDI) containing 200 doses of a bronchodilator. The patient has been instructed to take two puffs of the medication three times daily. At this dosage, how long will the MDI last? A. 100 days B. 50 days C. 66 days D. 33 days

D. 33 days

Which patient is least at risk for dysphagia? A. A 22-year-old patient with a traumatic brain injury (TBI) sustained during combat. B. A 40-year-old woman undergoing stroke rehabilitation who had been smoking and taking oral contraceptives. C. A 76-year-old patient with dementia. D. A 55-year-old patient with pancreatic cancer who is receiving palliative care.

D. A 55-year-old patient with pancreatic cancer who is receiving palliative care. The risk of dysphagia is elevated in any patient with generalized muscle weakness, altered mental status, or neurological impairment of the swallowing mechanism. Pancreatic cancer is not ordinarily associated with such conditions. Chemotherapeutic agents may cause dysphagia; the 55-year-old patient, however, is receiving only palliative care.

For which of the following patients would it be necessary to use a disposable shampoo cap, rather than a shampoo board? A. An older adult woman with a drainage tube in place following a mastectomy. B. An older adult man with a history of bleeding problems. C. A young woman whose arm and leg have been immobilized on the right side following a car accident. D. A young man who has sustained a fracture of the upper spine in a football game.

D. A young man who has sustained a fracture of the upper spine in a football game. *Head and neck injuries, such as this young man's spinal fracture, are a contraindication to use of a shampoo board because neck hyperextension could cause further injury.

If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step? A. Attempt to aspirate the site again. B. Prepare to access another IV site. C. Assess the saline lock site for signs of phlebitis. D. Assess the site for swelling or coolness while flushing the saline lock with normal saline.

D. Assess the site for swelling or coolness while flushing the saline lock with normal saline.

To make sure the drug is delivered properly, what discharge instructions might the nurse give a patient who is being discharged with a dry powder inhaler (DPI)? A. Rinse your mouth out with water after using the inhaler. B. Use the inhaler while sitting up in bed. C. Keep track of the dosage using the counter on the inhaler. D. After inhaling the medication, hold your breath for at least 10 seconds before exhaling.

D. After inhaling the medication, hold your breath for at least 10 seconds before exhaling. *The nurse would instruct the patient to hold his or her breath, which allows the medication to remain in contact longer with absorptive surfaces on the lungs.

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? A. Instruct the patient to report immediately any sign of bleeding on the site dressing. B. Perform hand hygiene and wear clean gloves while removing the device. C. Encourage the patient to keep a cold compress on the site for 15 minutes. D. Apply firm pressure to the site with sterile gauze for 10 minutes.

D. Apply firm pressure to the site with sterile gauze for 10 minutes. *Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot.

Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? A. Using a 1-inch needle B. Inserting the needle at a 45- to 60-degree angle C. Withdrawing the needle immediately after delivering the medication D. Aspirating for blood return before injecting the medication

D. Aspirating for blood return before injecting the medication

What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? A. Evaluate the patient's understanding of the combustible nature of oxygen. B. Arrange for a capable family member to be present during the initial discussion. C. Collect written information to present to the patient as supplemental instructional materials. D. Assess the patient's emotional readiness and physical ability to provide autonomous care.

D. Assess the patient's emotional readiness and physical ability to provide autonomous care.

The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care? A. Supine B. Prone C. Side-lying D. Dorsal recumbent

D. Dorsal recumbent

What can the nurse do to help protect the patient from infiltration of IV medication? A. Use the most proximal insertion port on the existing primary tubing. B. Ensure that the syringe has been securely loaded into the mini-infusion pump. C. Set the pump to deliver the medication over the prescribed time period. D. Check the IV site for placement before and after the infusion.

D. Check the IV site for placement before and after the infusion.

During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? A. Notify the health care provider of the patient's complaint. B. Request that the health care provider prescribe oxygen therapy. C. Interview the patient concerning the onset of this problem. D. Instruct the patient to use two bed pillows when lying supine.

D. Instruct the patient to use two bed pillows when lying supine.

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? A. White blood cell count B. Complete blood count C. X-ray of left foot D. Culture and sensitivity test

D. Culture and sensitivity test

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? A. Osteoarthritis B. Glaucoma C. Deafness D. Diabetes mellitus

D. Diabetes mellitus *Diabetes decreases tissue perfusion, impairing the supply of oxygen to the tissues. This slows wound healing.

How can the nurse ensure that medication from a single-dose vial is used appropriately? A. Check to see when the medication vial was opened initially. B. Write the date and his or her initials on the label when opening the vial. C. Draw the entire amount of medication from the vial into the syringe. D. Discard the vial and any remaining medication in the vial directly after use.

D. Discard the vial and any remaining medication in the vial directly after use.

What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? A. Lower the head of the bed. B. Remove the patient's eyeglasses. C. Have the patient cross the arms over the chest. D. Elevate the head of the bed.

D. Elevate the head of the bed. *The head of the bed is elevated immediately after the hooks are attached to the sling. The head of the bed is lowered before the sling is placed under the patient.

Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock? A. Use the most proximal insertion port on the primary tubing. B. Hang the piggyback solution higher than the primary infusion solution. C. Use a pump to regulate the infusion rate of the piggyback medication. D. Flush the saline lock with sodium chloride solution before initiating the infusion.

D. Flush the saline lock with sodium chloride solution before initiating the infusion. *Flushing the saline lock with 0.9% sodium chloride solution to assess for placement and patency before initiating a piggyback infusion reduces the likelihood of infiltration and extravasation.

What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? A. Notify the surgeon of the bleeding. B. Remove the dressing, and assess the wound. C. Assess the patient for signs of shock. D. Further assess the patient and the wound.

D. Further assess the patient and the wound. *Completing a further wound assessment and gathering more detailed information about the patient and his or her wound, such as pain level and amount of blood, would be the most appropriate action for the nurse to take. It is unnecessary to notify the surgeon, since such drainage is unlikely to indicate a surgical complication this late in the patient's recovery. The nurse would not remove the initial surgical dressing without an order to do so. Assessing the patient for shock is probably unnecessary this late in the patient's recovery.

The nurse has selected a finger as the puncture site to measure the blood glucose level of a female patient with type 2 diabetes mellitus and peripheral vascular disease (PVD). Although all of the actions listed below are appropriate, which one would be of particular benefit to this patient given her medical history? A. Reviewing her current medications B. Inspecting the selected finger for bruising C. Following standard precautions D. Keeping the finger in a dependent position during the puncture

D. Keeping the finger in a dependent position during the puncture The nurse would keep the finger in a dependent position to encourage blood flow to the intended puncture site. Blood flow to the extremities is compromised in patients with PVD.

5. What will the nurse do after opening a multi-dose vial and withdrawing a dose of medication from it? A. Discard the unused portion of the medication. B. Wipe the entire vial with an antiseptic swab. C. Send the unused portion back to the pharmacy. D. Label the vial with the date it was opened and your initials.

D. Label the vial with the date it was opened and your initials.

For which patient can the nurse delegate to nursing assistive personnel (NAP) the task of routine blood glucose monitoring? A. Patient with non-insulin-dependent diabetes for whom steroid therapy has been ordered B. Patient with type 2 diabetes who required insulin coverage at the last testing C. Patient with type 1 diabetes who has had nausea and vomiting for 24 hours D. Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist

D. Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist The patient with the closed reduction of a fracture of the right wrist would affect his or her ability to self-perform blood glucose testing but would not affect his or her blood glucose level. The skill of blood glucose testing may therefore be delegated to NAP. The patient's steroid therapy medication makes the blood glucose unstable, therefore the skill of blood glucose testing may not be delegated to NAP. The patient's need for insulin coverage precludes the delegation of blood glucose testing to NAP. The patient's nausea and vomiting make the blood glucose unstable, therefore the skill of blood glucose testing may not be delegated to NAP.

Which nursing action reduces the risk of falling as a patient is getting into or out of a bathtub? A. Add 1 oz of bath oil to the tub water before the patient gets into the tub. B. Place an "Occupied" sign on the bathroom door. C. Fill the tub half full of water at 110°F to 115°F. D. Place a skidproof disposable bath mat in front of the tub.

D. Place a skidproof disposable bath mat in front of the tub.

The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume? A. Place both feet together on the floor. B. Place your weaker foot forward and your stronger leg toward the back. C. Extend both of your legs and feet. D. Place your stronger leg forward and your weaker leg toward the back.

D. Place your stronger leg forward and your weaker leg toward the back.

How does the nurse minimize the risk of patient infection when preparing medication from an ampule? A. Using a filter needle to draw up the medication B. Preparing the medication in the patient's room C. Applying clean gloves while preparing the medication D. Preserving the sterility of the needle while preparing the medication

D. Preserving the sterility of the needle while preparing the medication

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? A. Lift the patient to place the device directly under him or her. B. Remove the drawsheet, and replace it with the device. C. Sit the patient up in the bed, and place the device behind the shoulders. D. Roll the patient from side to side, and place the device under the drawsheet.

D. Roll the patient from side to side, and place the device under the drawsheet.

What can the nurse do to ensure proper site selection for subcutaneous insulin injection? A. Insert the needle at a 30-degree angle. B. Select a different anatomical region for each injection. C. Ask the patient to relax before inserting the needle. D. Systematically rotate sites within the same anatomical location or area.

D. Systematically rotate sites within the same anatomical location or area.

When preparing to assist a patient with hair care, why does the nurse first check the patient's scalp for inflammation? A. To determine what type of shampoo to use B. To plan enough time to perform hair care C. To determine if the patient can perform the care independently D. To ensure that the care can be performed without injuring the scalp

D. To ensure that the care can be performed without injuring the scalp

What is the purpose of parting the patient's hair into sections? A. To identify the areas to be groomed B. To style the hair attractively C. To check for pediculosis (head lice) D. To make brushing and combing more effective

D. To make brushing and combing more effective

What is the primary reason for performing perineal care on a male patient with incontinence? A. To provide comfort and a relaxed, refreshed feeling B. To promote personal hygiene while minimizing perineal odor C. To remove all microorganisms from the patient's perineal area D. To reduce the risk of skin breakdown in the patient's genital and perineal area

D. To reduce the risk of skin breakdown in the patient's genital and perineal area *Incontinence increases the risk of skin breakdown, but proper perineal care minimizes the damaging effect that urine and feces have on the patient's skin.

The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned? A. To position the pillows B. To ease the patient back onto the support pillows C. To keep the spine in alignment D. To roll the patient as a unit

D. To roll the patient as a unit *Two assistants are needed to roll the patient as a unit, using one smooth, continuous motion. One assistant grasps the draw sheet at the lower hips and thighs, and the other assistant grasps the draw sheet at the patient's shoulders and lower back.

A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient? A. To apply moisturizer after air-drying thoroughly B. To apply moisturizer while the skin is still wet C. To skip the moisturizer D. To towel-dry thoroughly before applying moisturizer

D. To towel-dry thoroughly before applying moisturizer *The nurse would encourage this patient to towel dry thoroughly before applying moisturizer. Allowing the skin to air-dry promotes fungal growth and maceration of tissues.

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? A. Cleansing the wound with sterile water B. Blotting the incision with dry gauze C. Wearing sterile gloves to cleanse the wound D. Using a new gauze pad for each stroke while cleansing the wound

D. Using a new gauze pad for each stroke while cleansing the wound

Which action should the nurse avoid before irrigating a patient's foot wound? A. Assess the patient for a history of allergies to tape and irrigating solution. B. Review the provider's orders for the type of irrigating solution to be used. C. Assess the patient's pain on a scale of 0 to 10. D. Warm the irrigant to body temperature in the microwave.

D. Warm the irrigant to body temperature in the microwave.

Hemorrhoids

Dilated, engorged veins in the lining of the rectum

Oliguria

Diminished urinary output in relation to fluid intake

Hypertonic

Draw fluid from cells - Dextrose 5% in 0.45% Saline - Dextrose 5% in Normal Saline - Dextrose 5% in Lactated Ringers 3% or 5% Sodium Chloride (NaCl) - Dextrose 10% in water

Why would you take a BP in lower extremity?

Dressings, casts, IV catheters, or arteriovenous fistulas or shunts make the upper extremities inaccessible for BP measurement. You then need to obtain the BP in a lower extremity. Comparing upper-extremity BP with that in the legs is also necessary for patients with certain cardiac and BP abnormalities. The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation.

Safety risks in health care agencies include

Falls and the use of restraints. - Physical restraint: Mechanical or physical device, such as material or equipment attached or adjacent to the patient's body, used to restrict movement - Chemical restraint: Medication that is administered to a patient to control behavior

Starting a Peripheral IV

Finding a vein can be challenging - Go by "feel", not by sight. Good veins are bouncy to the touch, but are not always visible. - Use warm compresses and allow the arm to hang dependently to fill veins. - A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet. Arterial flow continues with maximum venous constriction. - If the patient is NOT allergic to latex, using a tourniquet may provide better venous congestion - Avoid areas of joint flexion - Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy

Plantar Warts

Fungating lesion appears on sole of foot and is caused by papilloma virus.

Trade (brand) name:

Given by the drug manufacture and identifies it as property of that company

Goal and related Outcomes in terms of medication administration

Goal: The patient will safely self-administer all ordered medications before discharge. Outcomes: +The patient verbalizes understanding of desired and adverse effects of medications. +The patient states signs, symptoms, and treatment of hypoglycemia.

Fluid Balance: Planning

Goals and outcomes - Establish an individual patient plan of care for each nursing diagnosis Setting priorities - The patient's clinical condition determines which of the nursing diagnoses takes the greatest priority Teamwork and collaboration

Sleep: Implementation

Health promotion - Environmental controls - Promoting bedtime routines - Promoting safety - Promoting comfort - Establishing periods of rest and sleep - Stress reduction - Bedtime snacks - Pharmacological approaches Environment controls - Promoting bedtime routines - Promoting safety - Promoting comfort - Establishing periods of rest and sleep - Stress reduction - Bedtime snacks - Pharmacological approaches Acute care - Environmental controls - Promoting comfort - Establishing periods of rest and sleep - Promoting safety - Stress reduction Restorative or continuing care - Promoting comfort - Controlling physiological disturbances - Pharmacological approaches

Hyperthermia

High body temperature - Malignant hyperthermia: is a condition that triggers a severe reaction to certain drugs used as part of anesthesia for surgery. Without prompt treatment, the disease can be fatal. The genes that cause malignant hyperthermia are inherited. *Can be heat exhaustion or heatstroke

What is hypotension?

Hypotension is present when the systolic BP falls to 90 mm Hg or below and diastolic falls below 60 mm Hg.

Define hypothermia

Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6 F (37 C). Hypothermia (hi-poe-THUR-me-uh) occurs as your body temperature falls below 95 F (35 C).

Circulatory overload of IV solution

IV solution infused too rapidly or in too great an amount Nursing Interventions: - If symptoms appear, reduce IV flow rate and notify patient's health care provider. - With ECV excess raise head of bed; administer oxygen and diuretics if ordered. - Monitor vital signs and laboratory reports of serum levels. - Health care provider may adjust additives in IV solution or type of IV fluid; watch for and implement order.

How to measure for Cuff Size

Ideally the width of the cuff is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb on which the cuff is used to measure BP. The inflatable bladder, contained in the occlusive cuff, encircles at least 80% of the upper arm of an adult and the entire arm a child.

Transient Incontinence

Incontinence caused by medical conditions that in many cases are treatable and reversible

Partial-thickness wound repair:

Inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers

Acne

Inflammatory, papulopustular skin eruption, usually involving bacterial breakdown of sebum; appears on face, neck, shoulders, and back - Wash hair and skin thoroughly each day with warm water and soap to remove oil. - Use cosmetics sparingly. Oily cosmetics or creams accumulate in pores and make condition worse. - Implement dietary restrictions if necessary. (Eliminate foods that aggravate condition from diet.) - Use prescribed topical antibiotics for severe forms of acne.

Local infection

Infection at catheter-skin entry point during infusion or after removal of IV catheter Assessment Findings: Redness, heat, swelling at catheter-skin entry point; possible purulent drainage Nursing Interventions: - Culture any drainage (if ordered). - Clean skin with alcohol; remove catheter and save for culture; apply sterile dressing. - Notify health care provider. - Start new IV line in other extremity. - Initiate appropriate wound care if needed.

Phlebitis

Inflammation of inner layer of a vein Assessment Findings: Redness, tenderness, pain, warmth along course of vein starting at access site; possible red streak and/or palpable cord along vein Nursing Interventions: - Stop infusion and discontinue IV line. - Start new IV line in other extremity or proximal to previous insertion site if continued IV therapy is necessary. - Apply warm, moist compress or contact IV therapy team or health care provider if area needs additional treatment.

Extracelluar Fluid Volume Excess

Input is greater than your output - Possible causes: SIADH - S&S - edema, SOB, increased HR and BP, crackles in the lungs, neck veins distended, weight gain of 2.2. lbs in 24 hour period. - As a nurse monitor weight, check for pitting, measure intake and output

Extracellular Fluid Volume Deficit

Intake less than output puts you at risk for dehydration - Possible causes: vomiting, diarrhea, wound drainage, hemorrhage, burns, inability to access fluids, impaired swallowing, NPO status - S&S: thready pulse, decreased BP, postural hypotension, skin turgor, dry mucous membranes, concentrated urine, rapid pulse, weight loss of 2.2 lbs in 24 hours, weak, thirsty (old people lose ability to feel thirst putting them at risk), neck veins flat

Intraocular

Intraocular medication delivery involves inserting a medication similar to a contact lens into a patient's eye. The eye medication disk has two soft outer layers that have medication enclosed in them. The nurse inserts the disk into the patient's eye, much like a contact lens. The medication remains in the eye for up to 1 week.

Stress Urinary Incontinence

Involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter (e.g., weak pelvic floor muscles, trauma after childbirth, radical prostatectomy) Result of weakness or injury to the urinary sphincter or pelvic floor muscles Underlying result: urethra cannot stay closed as pressure increases in the bladder as a result of increased abdominal pressure (e.g., a sneeze or cough)

Reflex Urinary Incontinence

Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2

Urge or Urgency Urinary Incontinence

Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction In many cases bladder overactivity is idiopathic; cause is not known Caused by involuntary contractions of the bladder associated with an urge to void that causes leakage of urine

Sponge bath at the sink:

Involves bathing from a bath basin or sink with patient sitting in a chair. Patient is able to perform part of the bath independently. Assistance is needed for hard-to-reach areas.

Tub bath:

Involves immersion in a tub of water that allows more thorough washing and rinsing than a bed bath. Commonly used in long-term care. A patient may require the nurse's help. Some institutions have tubs equipped with lifting devices that facilitate positioning dependent patients in the tub.

Why is assessment of ROM important?

Is important as a baseline measure to determine a patient's mobility status and to later compare and evaluate whether a loss in joint mobility has occurred as a result of clinical changes or treatments.

Hyperpnea

Is increased depth and rate of breathing.

What is Safety?

Is the condition of being free from physical or psychological harm and injury.

What is ROM?

Is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal.

Isolation and Isolation Precautions

Isolation is the separation and restriction of movement of ill persons with contagious diseases. - Barrier precautions - Standard precautions - Isolation precautions: airborne, droplet, contact, and protective environment *Transmission based precautions = airborne, droplet, or contact

Identify behavioral changes associated with sensory overload.

It is easy to confuse the behavioral changes associated with sensory overload with mood swings or simple disorientation. Look for symptoms such as racing thoughts, scattered attention, restlessness, and anxiety. Patients in intensive care units (ICUs) sometimes constantly play with tubes and dressings. Constant reorientation and control of excessive stimuli become an important part of a patient's care.

Implementation - Dressings: Changing Dressings

Know type of dressing, placement of drains, and equipment needed. Prepare the patient for a dressing change. - Review previous wound assessment. - Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change. - Describe procedure steps to lessen patient anxiety. - Gather all supplies. - Recognize normal signs of healing. - Answer questions about the procedure or wound.

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further

Leave the catheter there and start over with a new catheter

Skeletal System: Ligaments

Ligaments bind joints together and connect bones and cartilage.

Functional Incontinence

Loss of continence because of causes outside the urinary tract Usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, poor motivation, or environmental barriers Direct result of caregivers not responding in a timely manner to requests for help with toileting

Hypokalemia

Low potassium

Factors that affect sensory function: Meaningful stimuli

Meaningful stimuli reduce the incidence of sensory deprivation. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings.

Topical

Medications applied to the skin and mucous membranes generally have local effects. You apply topical medications to the skin by painting or spreading the medication over an area, applying moist dressings, soaking body parts in a solution, or giving medicated baths. Systemic effects often occur if a patient's skin is thin or broken down, the medication concentration is high, or contact with the skin is prolonged. A transdermal disk or patch (e.g., nitroglycerin, scopolamine, and estrogens) has systemic effects. The disk secures the medicated ointment to the skin. These topical applications are left in place for as little as 12 hours or as long as 7 days.

Circumduction

Moving the arm in a circle around the shoulder

Implementation and Evaluation: The risk for an electric shock may be increased for patients who

Need electrical equipment for therapeutic purposes.

Pulse rate

Number of pulsing sensations in 1 minute.

What is orthostatic hypotension?

Occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 10 mm Hg within 3 minutes of rising to an upright position

Electrical Shock

Occurs when a person comes in contact with an energy source and the energy flows through the body or portion of the body to the ground

Lead poisoning

Occurs when lead levels build up in blood over months or years

Central Venous Catheters

PICC- Peripherally Inserted Central Venous Catheter:Usually put in in upper arm. Sterile technique - Can have one port or two ports. Can stay in up to a year. When you flush, if there is resistance met, do not force because there could be a clot. Dressing changes every 7 days. Central Venous Catheters - Port a Cath - Subclavian - Internal Jugular *Any of these put in you have to X-ray to make sure it is sitting correctly.

Dysuria

Pain or discomfort associated with voiding

Parenteral Nutrition (PN)

Parenteral nutrition is a form of nutritional support that supplies protein, carbohydrate, fat, electrolytes, vitamins, minerals, and fluids via the IV route to meet the metabolic functioning of the body. - Administered via central catheter - Glucose monitoring

Establishing Safe Environments: Adaptations for Reduced Hearing

Patients hear important environmental sounds (e.g., doorbells and alarm clocks) best if they are amplified or changed to a lower-pitched, buzzer-like sound. Lamps designed to turn on in response to sounds such as doorbells, burglar alarms, smoke detectors, and babies crying are also available. Family members and anyone who calls the patient regularly need to learn to let the phone ring for a longer period. Amplified receivers for telephones and telephone communication devices (TCDs) are available that use a computer and printer to transfer words over the telephone for the hearing impaired. Both sender and receiver need to have the special device to complete a call.

Establishing Safe Environments: Adaptations for Reduced Olfaction

Patients hear important environmental sounds (e.g., doorbells and alarm clocks) best if they are amplified or changed to a lower-pitched, buzzer-like sound. Lamps designed to turn on in response to sounds such as doorbells, burglar alarms, smoke detectors, and babies crying are also available. Family members and anyone who calls the patient regularly need to learn to let the phone ring for a longer period. Amplified receivers for telephones and telephone communication devices (TCDs) are available that use a computer and printer to transfer words over the telephone for the hearing impaired. Both sender and receiver need to have the special device to complete a call.

Promoting Meaningful Stimulation: Touch

Patients with reduced tactile sensation usually have the impairment over a limited part of their bodies. Providing touch therapy stimulates existing function. If a patient is willing to be touched, hair brushing and combing, a backrub, and touching the arms or shoulders are ways of increasing tactile contact. When sensation is reduced, a firm pressure is often necessary for a patient to feel a nurse's hand. Turning and repositioning also improves the quality of tactile sensation. If a patient is overly sensitive to tactile stimuli (hyperesthesia), minimize irritating stimuli. Keeping bed linens loose to minimize direct contact with a patient and protecting the skin from exposure to irritants are helpful measures. Physical therapists can recommend special wrist splints for patients to wear to dorsiflex their wrists and relieve nerve pressure when they have numbness and tingling or pain in the hands, as with carpal tunnel syndrome. For patients who use computers, special keyboards and wrist pads are available to decrease the pressure on the median nerve, aid in pain relief, and promote healing.

Intravenous Access Devices

Peripheral IVs: Change every 96 hours - Continuous - Intermittent- Saline Lock (not being used continuously, used to administer meds and stuff) - Short term- Butterfly

Korotkoff sound descriptions:

Phase 1 - First faint, clear tapping or thumping sounds - Systolic pressure Phase 2 - Muffled, whooshing, or swishing sound Phase 3 - Blood flows freely - Crisper and more intense sound - Thumping quality but softer than in phase 1 Phase 4 - Muffled and have a soft, blowing sound Phase 5 - Pressure level when the last sound is heard - Period of silence - Diastolic pressure

Describe the use of the following with rationale(s): Pillows

Pillows are positioning aids and are sometimes readily available. - Before using a pillow, determine whether it is the proper size. - A thick pillow under a patient's head increases cervical flexion, which is not desirable. - A thin pillow under bony prominences does not protect skin and tissue from damage caused by pressure. - When additional pillows are unavailable or if they are an improper size, use folded sheets, blankets, or towels as positioning aids.

Hematuria

Presence of blood in urine Gross hematuria (blood is easily seen in urine) Microscopic hematuria (blood not visualized but measured on urinalysis)

Promoting Meaningful Stimulation: Taste and Smell

Promote the sense of taste by using measures to enhance remaining taste perception. Good oral hygiene keeps the taste buds well hydrated. Well-seasoned, differently textured food eaten separately heightens taste perception. Flavored vinegar or lemon juice adds tartness to food. Always ask a patient which foods are most appealing. Improving taste perception improves food intake and appetite as well. Stimulation of the sense of smell with aromas such as brewed coffee, cooked garlic, and baked bread heightens taste sensation. Patients need to avoid blending or mixing foods because these actions make it difficult to identify tastes. Older people need to chew food thoroughly to allow more food to contact remaining taste buds. Improve smell by strengthening pleasant olfactory stimulation. Make a patient's environment more pleasant with smells such as cologne, mild room deodorizers, fragrant flowers, and sachets. Consult with patients to find out which scents they can tolerate. The removal of unpleasant odors (e.g., bedpans or soiled dressings) also improves the quality of a patient's environment.

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________________.

Promote venous return to the heart.

What are the three components of a sensory experience? Briefly discuss each.

Reception, perception, and reaction are the three components of any sensory experience. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound. In the case of special senses, the receptors are grouped close together or located in specialized organs such as the taste buds of the tongue or the retina of the eye. When a nerve impulse is created, it travels along pathways to the spinal cord or directly to the brain. For example, sound waves stimulate hair cell receptors within the organ of Corti in the ear, which causes impulses to travel along the eighth cranial nerve to the acoustic area of the temporal lobe. Sensory nerve pathways usually cross over to send stimuli to opposite sides of the brain. The actual perception or awareness of unique sensations depends on the receiving region of the cerebral cortex, where specialized neurons interpret the quality and nature of sensory stimuli. When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli on the basis of the person's experiences. A person's level of consciousness influences perception and interpretation of stimuli. Any factors lowering consciousness impair sensory perception. If sensation is incomplete such as blurred vision or if past experience is inadequate for understanding stimuli such as pain, the person can react inappropriately to the sensory stimulus. It is impossible to react to all stimuli entering the nervous system. The brain prevents sensory bombardment by discarding or storing sensory information. A person usually reacts to stimuli that are most meaningful or significant at the time. After continued reception of the same stimulus, a person stops responding, and the sensory experience goes unnoticed. For example, a person concentrating on reading a good book is not aware of background music. This adaptability phenomenon occurs with most sensory stimuli except for those of pain.

Risk Factors for Hygiene Care: Eye Care Problems

Reduced dexterity and hand coordination ---> Physical limitations create inability to safely insert or remove contact lenses.

What are unintentional injuries?

Result from incidents such as falls, motor vehicle crashes, poisonings, drownings, fire-associated injuries, suffocation by ingested objects, and firearms.

Drug toxicity

Result from overdose, ingestion of external use drug, or buildup of drug in blood

Impaction

Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel

Partial-thickness wounds:

Shallow in depth, moist and painful, and the wound base generally appears red

Hypotonic

Shift fluid into cells - 0.225% sodium chloride - 0.45% sodium chloride

Sublingual

Some medications (e.g., nitroglycerin) are readily absorbed after being placed under the tongue to dissolve. Instruct patients not to swallow a medication given by the sublingual route or drink anything until the medication is completely dissolved to ensure that the medication will have the desired effect.

PRN order:

Sometimes the health care provider orders a medication to be given only when a patient requires it. This is a prn order. Use objective and subjective assessment (e.g., severity of pain, body temperature) and discretion in determining whether or not the patient needs the medication. *Has to have what it is being used for

Toxins

Substances that can poison or harm individuals or other living organisms through ingestion, inhalation, and dermatologic exposure

Febrile nonhemolytic (most common)

Sudden shaking chills (rigors), fever (rise in temperature 0.5° C [1° F] or more from start), headache, flushing, anxiety, muscle pain Cause: - Antibodies against donor white blood cells

Apnea

Temporary cessation of breathing, especially during sleep

Skeletal System: Tendons

Tendons connect muscles to bone.

Patient Hygiene Needs: Planning

The FAMILY & the PATIENT must be included in the plan of care. - Establish goals for nursing diagnosis - Establish outcomes for goals: (specific, measurable, time-bounded, realistic) - Plan interventions: with rationals

Inhalation

The deeper passages of the respiratory tract provide a large surface area for medication absorption. Nurses administer inhaled medications through the nasal and oral passages or endotracheal or tracheostomy tubes. Endotracheal tubes enter the patient's mouth and end in the trachea, whereas tracheostomy tubes enter the trachea directly through an incision made in the neck. Inhaled medications are readily absorbed and work rapidly because of the rich vascular alveolar capillary network present in the pulmonary tissue. Many inhaled medications have local or systemic effects.

What are areas that needs constant care for patients with self-help deficit?

The eyes, ears, and nose *Failure to meet these needs can put a patients for other health risks.

Communicable disease:

The infectious process transmitted from one person to another.

Phlebitis

The inflammation of a vein, usually in the legs. Phlebitis may occur with or without a blood clot. It can affect surface or deep veins. When caused by a blood clot, it's called thrombophlebitis. Trauma to the vein, for instance from an IV catheter, is a possible cause. - Symptoms include redness, warmth, and pain in the affected area.

Body sites commonly used for intradermal injections

The inner forearm and upper back are ideal locations. - Tuberculin testing or allergy testing - Small amounts of solution; 0.01 to 0.1 mL - Fine gauge needle, 25 to 27; ½ to 5/8-inch - 5 to 15-degree angle

Abduction

The movement of a limb or other part away from the midline of the body

Promoting Meaningful Stimulation: Vision

The pupil's ability to adjust to light diminishes as a result of the normal changes of aging; thus older adults are often very sensitive to glare. Suggest the use of yellow or amber lenses and shades or blinds on windows to minimize glare. Wearing sunglasses outside obviously reduces the glare of direct sunlight. Other interventions to enhance vision for patients with visual impairment include warm incandescent lighting and colors with sharp contrast and intensity. The ability to read is important. Therefore allow patients to use their glasses whenever possible (e.g., during procedures and instruction). Some patients with reduced visual acuity need more than corrective lenses. A pocket magnifier helps a patient read most printed material. Telescopic-lens eyeglasses are smaller, easier to focus, and have a greater range. Books and other publications are also available in larger print. If a patient has a legal or another important document that he or she wishes to read, standard copying machines have enlarging capabilities. Software is also available that converts text into artificial voice output. With aging a person experiences a change in color perception. Perception of the colors blue, violet, and green usually declines. Brighter colors such as red, orange, and yellow are easier to see. Offer suggestions of ways to decorate a room and paint hallways or stairwells so the patient is able to differentiate surfaces and objects in a room.

Dermis

The thicker layer, contains the bundles of collagen & fibers to protect the epidermis (nerves, glands, etc)

What is the difference between reception and perception?

The welcoming stimuli from nerve endings is termed as reception. The deciphering of impulses from receptors and the giving of connotation to the stimuli is termed perception.

Prescription

The written direction for the preparation and administration of a drug

Callus

Thickened part of epidermis consists of mass of horny, keratotic cells. Callus is usually flat, painless, and found on undersurface of foot or palm of hand.

What are intentional injuries?

Typically result from deliberate acts of violence or abuse and often have fatal consequences such as suicide and homicide.

Idiosyncratic Reactions

Unpredictable effects - patient overreacts or underreacts to a medication.

After evaluation, each patient's safety care plan is

Updated to reflect changes in his or her condition.

Common Symptoms of Urinary Alterations

Urgency Dysuria Frequency Hesitancy Polyuria Oliguria Nocturia Dribbling Hematuria Retention

IV: Equipment

Vascular access devices (VADs), tourniquets, clean gloves, dressings, IV fluid containers, various types of tubing, and electronic infusion devices (EIDs), also called infusion pumps

One of the most important things we can do as nurses to prevent spread of disease is

Wash our hands

How does sensory overload occur?

When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation prevents the brain from responding appropriately to or ignoring certain stimuli. Because of the multitude of stimuli leading to overload, a person no longer perceives the environment in a way that makes sense. Overload prevents meaningful response by the brain; the patient's thoughts race, attention scatters in many directions, and anxiety and restlessness occur. As a result, overload causes a state similar to that produced by sensory deprivation. However, in contrast to deprivation, overload is individualized. The amount of stimuli necessary for healthy function varies with each individual. People are often subject to environmental overload more at one time than another. A person's tolerance to sensory overload varies with level of fatigue, attitude, and emotional and physical well-being.

Establishing Safe Environments: Adaptations for Reduced Tactile Sensation

When patients have reduced sensation in their extremities, they are at risk for impaired skin integrity and injury from exposure to temperature extremes. Always caution these patients about the use of heating and cooling devices (see Chapter 48). The temperature setting on the home water heater should be no higher than 48.8° C (120° F). If a patient also has a visual impairment, it is important to be sure that water faucets are clearly marked "hot" and "cold" or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this population.

Sleep disorders are conditions that, if untreated, generally cause disturbed nighttime sleep that results in one of three problems:

insomnia, abnormal movements or sensation during sleep or when awakening at night, or excessive daytime sleepiness.

Performing Urinary Catheterization: Secure the catheter to the _______ of a female client.

thigh

Risks for infections in older adults:

• An age-related functional deterioration in immune system function, termed immune senescence, increases the susceptibility of the body to infection and slows overall immune response. • Older adults are less capable of producing lymphocytes to combat challenges to the immune system. When antibodies are produced, the duration of their response is shorter, and fewer cells are produced. • Risks associated with the development of infections or HAIs in older patients include poor nutrition, unintentional weight loss, lack of exercise, poor social support, and low serum albumin levels. • Flu and pneumonia vaccinations are recommended for the older-adult population to reduce their risk for infectious diseases. • Teach older adults and their families how to reduce the risk for infections by using proper hand hygiene practices.

Use all six CHG cloths in the following order:

• Cloth 1: Neck, shoulders, and chest • Cloth 2: Both arms, both hands, web spaces, and axilla • Cloth 3: Abdomen and then groin/perineum • Cloth 4: Right leg, right foot, and web spaces • Cloth 5: Left leg, left foot, and web spaces • Cloth 6: Back of neck, back, and buttocks

Nursing Diagnosis - Related to Fluid Volume

• Decreased cardiac output • Acute confusion • Impaired gas exchange • Excess fluid volume • Risk for electrolyte imbalance • Deficient knowledge regarding disease management: risk for injury • Deficient fluid volume

The following are common trouble areas for a patient in the supported Fowler's position:

• Increased cervical flexion because the pillow at the head is too thick and the head thrusts forward • Extension of the knees, allowing the patient to slide to the foot of the bed • Pressure on the posterior aspect of the knees, decreasing circulation to the feet • External rotation of the hips • Arms hanging unsupported at the patient's sides • Unsupported feet or pressure on the heels • Unprotected pressure points at the sacrum and heels • Increased shearing force on the back and heels when the head of the bed is raised greater than 60 degrees

Trouble points common in Sims' position include the following:

• Lateral flexion of the neck • Internal rotation, adduction, or lack of support to the shoulders and hips • Lack of foot support • Lack of protection for pressure points at the ileum, humerus, clavicle, knees, and ankles

The following trouble points are common in the side-lying position:

• Lateral flexion of the neck • Spinal curves out of normal alignment • Shoulder and hip joints internally rotated, adducted, or unsupported • Lack of foot support • Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles • Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist

Helping Patients to Exercise: Instruct NAP to do the following:

• Notify nurse if patient reports pain before, during, or after exercise. • Notify nurse if patient complains of increased fatigue, dizziness, or light-headedness when obtaining preexercise and/or post-exercise vital signs. • Notify nurse of vital sign values.