unit 4/5 pt 2

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate? The radial pulse is more rapid than the apical pulse. This is a normal finding and should be ignored. The client's arteries are very compliant. Not all of the heartbeats are reaching the periphery.

Not all of the heartbeats are reaching the periphery.

When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply. The head is held erect. The feet are at right angles to the lower legs. The arms are bent at the elbows. The chest is held upward and forward. The knees are bent.

The arms are bent at the elbows. The knees are bent.

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

raising the height of the bed to the waist level prior to moving the client

The nurse is caring for a client who has been prescribed patient controlled analgesia (PCA) pump to manage postoperative pain. The client tells the nurse, "I am really scared that I will end up with an overdose on this medication." What is the nurse's best response? "Do you have a health history of drug addiction?" "At least you do not need frequent injections." "The device is controlled by the nurse only so you will be safe." "Less of the drug is required to control pain by this method."

"Less of the drug is required to control pain by this method."

Which statement accurately describes pain experienced by the older adult? Boredom and depression may affect an older person's perception of pain. Residents in long-term care facilities have a minimal level of pain. The older client has decreased sensitivity to pain. A heightened pain tolerance occurs in the older adult.

Boredom and depression may affect an older person's perception of pain.

About which issue should the nurse inform clients who use pain medications on a regular basis? Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Minimize fiber intake during the therapy. Consume the medications just before or along with meals.

Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician.

A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient? A migraine headache An exacerbation of rheumatoid arthritis Low back pain Sickle cell crisis

Low back pain

Which client's vital signs will the nurse assess every four hours? a client in a critical care unit in septic shock a client hospitalized with hypertension a resident in a long-term care facility a client receiving intravenous antibiotics as an outpatient

a client hospitalized with hypertension

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? B/P 178/92 and pulse 118 confused to time and place right shoulder immobilizer in place rates pain an 8 on a 0 to 10 scale

confused to time and place

The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action?

constant use of mosquito repellent

The action of ibuprofen is to: provide narcotic pain relief. have an antiprostaglandin effect on the CNS. close the gate of the A-delta fibers. enhance the endorphins of the CNS.

have an antiprostaglandin effect on the CNS.

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing? transduction transmission perception modulation

modulation

Which principle in pain management is the point beyond which a person is no longer willing to endure pain?

pain tolerence

The nurse is caring for a 7-year-old who has suddenly developed difficulty hearing in the left ear. Which nursing action is appropriate? performing a thorough inspection of the ear. preparing for ear irrigation placing a cotton ball in the left ear occluding the ear canal with the tip of a syringe

performing a thorough inspection of the ear.

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be mostappropriate? "The baby is showing how it is adapting to the environmental temperature." "It is common for newborns to have body temperatures less than 36.4°C (97.6°F)." "It is because of the immature ability to regulate temperature in general." "It is because of the closely woven dark fabric wrapped around the baby."

"It is because of the immature ability to regulate temperature in general."

A nurse is assessing the cardiac output of a client at the health care facility. What would the nurse identify as the average cardiac output in a resting person?

5.5 L

The health care provider has prescribed heat therapy for a client's leg wound. What will the nurse explain to the client about the application of heat therapy? A 15- to 20-minute application will promote healing and consolidation of pus. A 15- to 20-minute application will decrease inflammation by accelerating the inflammatory process. A 15- to 20-minute application will control the bleeding by causing vasoconstriction. A 15- to 20-minute application will relieve pain by decreasing nerve conduction velocity.

A 15- to 20-minute application will promote healing and consolidation of pus.

A clinic nurse is caring for a male client diagnosed with gonorrhea who has been prescribed ceftriaxone and doxycycline. The client asks why he is receiving two antibiotics. What is the nurse's best response?

Many people infected with gonorrhea are infected with chlamydia as well."

The nursing instructor is discussing the development of human immunodeficiency disease (HIV) with the students. What should the instructor inform the class about helper T cells? They are activated on recognition of antigens and stimulate the rest of the immune system. They attack the antigen directly by altering the cell membrane and causing cell lysis. They have the ability to decrease B-cell production. They are responsible for recognizing antigens from previous exposure and mounting an immune response.

They are activated on recognition of antigens and stimulate the rest of the immune system.

All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned? an older adult a pregnant adolescent a junior high football player an infant 2 months of age

an infant 2 months of age

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation? diaphoresis conduction convection radiation

diaphoresis

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage? circular turn only spiral turn figure-of-eight turn recurrent bandaging

figure-of-eight turn

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: neutrophils and monocytes. plasma cells and memory cells. regulator T cells and helper T cells. lymphokines and suppressor T cells.

neutrophils and monocytes.

A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document?

presencence of abnormalities that implied health

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory? asking if pain is produced by smells or sounds providing temple massage when head hurts teaching the client to remove items from the home that remind them of work contacting the health care provider to prescribe opioid medication

providing temple massage when head hurts

The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings? absent and infrequent shallow and slow rapid and deep noisy and difficult

rapid and deep

The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment?

asses nonverbal cues

During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply. virulence infectious agent portal of entry susceptible host fomites

infectious agent portal of entry susceptible host

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? serous purulent serosanguineous sanguineous

serosanguineous

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed?

the client pushes the walker ahead, following behind it.