ATI FUNDAMENTALS M

NURSING INTERVENTION: IV site, palpable cord - phlebitis

A client who has a palpable cord along the vein might have phlebitis, which is inflammation of the inner layer of a vein. - discontinue the infusion - start a new IV line in another location.

NURSING INTERVENTION: redness at IV catheter entry

A client who has redness at the IV catheter entry site might have a local infection. - remove the IV, clean the site with alcohol - start a new IV line in another location.

NURSING INTERVENTION: infiltrated IV site

A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. - stop the IV infusion, - elevate the extremity - apply a warm moist compress or a cold compress (according to the type of infiltration).

living will document

A living will contains advance directives that inform medical personnel about the care to provide in case the individual is unable to make decisions.

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Centers for Disease Control and Prevention recommend washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. - should be performed with warm water, which preserves the protective oil of the skin better than hot water. - friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds. - drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization

A. A client who has a prescription for a transfusion of packed red blood cells Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.

supine position

lying flat on the back.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

A. Collect the specimen when the client rises in the morning The nurse should plan to collect the sputum specimen when the client arises in the morning because the client will be able to cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.

prone position

lying on the abdomen.

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. mask

A. Gloves According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least contaminated piece of PPE.

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood glucose level C. Decreased oxygen use D. Increased gastrointestinal motility

A. Increased blood pressure The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood pressure and heart rate as a result of sympathetic stimulation. - manifest an increase in blood glucose due to the release of glucocorticoids and gluconeogenesis. - manifest an increase in oxygen use due to the increased metabolic rate and oxygen demands of the body. - manifest decreased gastrointestinal motility, which can result in constipation and flatus.

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Provide oral care to a client who cannot take oral fluids B. Check a client's IV insertion site for manifestations of infiltration C. Assess a client's ability to ambulate D. Demonstrate the use of a glucometer to a client who has diabetes mellitus

A. Provide oral care to a client who cannot take oral fluids Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP.

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? A. Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temperature D. Secretion of hormones needed for growth

A. Regulation of acid-base balance The nurse should identify that the kidneys assist with the regulation of acid-base balance in the body by retaining bicarbonate as they excrete hydrogen ions.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restrains within 24 hr B. Secure the restraint with the buckle side next to the client's skin C. Ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hr

A. Renew the prescription for the use of restrains within 24 hr The nurse should plan to renew the prescription for the restraints within 24 hours, only after the provider has evaluated the client. - secure with the softer side next to skin with the buckle or Velcro closure on the outside. - ensure 2 fingers, unable to insert 2 fingers, could cause impaired circulation to the extremities. - remove at least every 2 hours; at that time, check skin, change position, and toilet or exercise the client.

HEART SOUND: audible click

An audible clicking sound occurs in clients who have undergone prosthetic valve replacement surgery.

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke D. A client who has cancer and receives weekly radiation therapy

B. A client who has end-stage cirrhosis A client who has end-stage cirrhosis likely has a life expectancy of ≤6 months. Therefore, this client is eligible for hospice services.

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

B. Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration. - Redness and Warmth at the infusion site = phlebitis or infection. - Oozing of blood at the infusion site =IV system is not intact.

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue the teaching, but check afterward with the surgeon about informed consent. B. Stop the teaching and check with the surgeon about informed consent. C. Stop the teaching and ask the client to sign an informed consent form. D. Continue the teaching and check the client's medical record afterward for a signed consent form.

B. Stop the teaching and check with the surgeon about informed consent. The client's statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon.

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. "I should rinse my mouth out right before I use the inhaler." B. "After the first puff, I will wait 10 seconds before taking the second puff." C. "I will shake the inhaler well right before I use it." D. "I will tilt my head forward while inhaling the medication."

C. "I will shake the inhaler well right before I use it." The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

C. "Let's set up a meeting time with the doctor to discuss your options for home care." In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment.

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility

C. Assigning another client with the same infection to share the room with the client The nurse can place clients who are infected with the same room if a private room is not available - do not shake soiled linen because this action can transfer microorganisms. - wear a mask when working within 1 m (3.3 ft) of a client who is on droplet precautions - strictly limit the client's activity outside the room Whenever the client has to leave the room, the nurse should place a mask on the client.

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior tibial C. Dorsalis pedis D. Femoral

C. Dorsalis pedis The nurse should identify that the dorsalis pedis pulse is located on the top of the foot, following the groove between the tendons of the great toe. It is best felt by moving the fingertip between the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is congenitally absent in some clients.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream

C. Gelatin Foods allowed on a clear liquid diet are clear and liquid at room temperature.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask someone to stay with the client B. Offer to call the client's minister C. Sit and hold the client's hand D. Leave the room and allow the client to cry privately

C. Sit and hold the client's hand This action uses the therapeutic communication techniques of silence, touch, and offering of self to the client.

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration).

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently Bearing down helps the nurse visualize the urinary meatus and relaxes the external sphincter, which facilitates the insertion of the catheter.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

D. Check the client's perineum Nursing action is for the nurse to collect more data by assessing the area of irritation. - apply a fecal collection system to divert the feces away from the area of skin irritation; - apply a barrier cream to decrease skin breakdown in the perianal area from the feces; - cleanse and dry the perianal area to decrease

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document

D. Durable power of attorney document A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's

D. Fowler's This describes Fowler's position. Although various definitions exist for Fowler's position, generally a low Fowler's position means 30° of elevation, semi Fowler's is 45° to 60°, and high Fowler's is 60° to 90° of elevation.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.

D. Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection.

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side-lying position C. Provide privacy D. Lower the client to the floor

D. Lower the client to the floor If a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect the client from injury.

acceptance stage of grief

During the acceptance stage of grief, integrates the loss into his or her life (e.g. by making final arrangements).

anger stage of grief

During the anger stage of grief, shows resistance or blames other people, a higher power, or the situation itself

NURSING ASSESSMENT - hypercalcemia

Hypercalcemia occurs when calcium level is <10.5 mg/dL. - assess the client for lethargy, weakness, and other clinical manifestations

technique to assess capillary refill

Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink

how to conduct chvostek's sign

Tap in front of the tragus 2- 3 cm below, along the course of the facial nerve. If patient has hypocalcemia this maneuver would cause twitching of the face and lip. = positive chvostek's sign

Medication Administration

The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration. - In an inpatient setting, responsible for administering medication to the client. - If the nurse returns to the client's room in 30 minutes, the nurse will not be able to verify that the client took the medication since the client could have hidden or discarded the medication. - responsible for administering the medication at the scheduled time. - generally may be given within 1 hour of prescribed time (i.e. ≤30 minutes prior to or ≤30 minutes after the prescribed time of administration).

full liquid diet

clear liquids + liquid dairy products, all juice, strained fruits, vegetables, and cereals - Cream of rice - Ice cream

Removing PPE sequence

gloves, goggles, gown, mask

soft diet.

special diet containing only foods that are soft in texture - Cottage cheese

sputum culture and sensitivity (C&S)

- Collect the specimen when the client rises in the morning, client will be able to cough up the secretions that have accumulated during the night. - instruct to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container - Collect when the client rises in the morning - encourage to force fluids, especially clear liquids, to help thin respiratory secretions. - evening hours are not the preferred time - collect before the client receives antibiotic therapy to prevent interference with the laboratory results. -collect 4 to 10 mL of sputum before sending the specimen to the laboratory

potassium normal levels

3.5-5.0 mEq/L

Calcium normal levels

8.5-10.5 mg/dL

A DNR (do-not-rescusitate) directive

A DNR directive is a prescription the provider writes on the client's request to instruct the staff to forego resuscitation efforts for the client.

WOUND: secondary intention

A beefy, red tissue called granulation tissue fills the wound during healing. - wound is left open to drain and heal by secondary intention, - occurs within 5 to 21 days. - Open wounds increase the risk of wound infection.

HEART SOUND: heart murmur

A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease.

HEART SOUND: third heart sound

A third heart sound (S3) is a low-pitched noise after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day." C. "I will call the nurse to change my bed linens." D. "I will call the nurse to help me bathe in the morning."

A. "A nurse will show me how to care for my wound." The home health nurse will provide wound care as prescribed and educate the client about wound care and illness management.

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. This approach reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the tubing or the client lying on it.

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium

A. Decreased calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? A. The client watches television in her bed during the day. B. The client drinks warm milk before bedtime. C. The client goes to bed at 2200 every night. D. The client gets up to use the bathroom once during the night.

A. The client watches television in her bed during the day. To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

B. Fidelity The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound

B. Keeping microorganisms from entering the wound Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound.

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? A. "The home health dietitian will visit and help you learn to cook all over again." B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control." C. "The dietitian will help you choose foods you are used to that also meet your health needs." D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian."

C. "The dietitian will help you choose foods you are used to that also meet your health needs." This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods.

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial

D. Denial During the denial stage of grief, a client is unable to accept the reality of the loss. A client who has a terminal disease has a limited amount of time, so building a house is unrealistic and denies reality.

WOUND: primary intention

Primary intention involves the closing of the wound using sutures or staples at the time the incision is made; - the suture line edges become well-approximated during healing.

informed consent

Prior to specific procedures, clients must sign an informed consent form to confirm that the provider has explained the risks and benefits and pertinent information about the procedure.

popliteal pulse location

behind the knee - best felt with the client's knee slightly flexed and the foot resting on an examination table.

sims position

lies on a side with the leg on that side slightly flexed and the opposite leg more acutely flexed. The lower arm is behind, with the opposite arm flexed at the shoulder and the elbow.

nonmaleficence

the ethical principle of nonmaleficence involves doing no harm.

clear liquid diet

a diet that consists of foods that are liquid at room temperature and leave little residue in the intestine. Ex: Water, Sprite, Ginger Ale, all beverages without any residue, broth, Jello - gelatin

femoral pulse location

in the inguinal area - best felt with the client lying down and the inguinal area exposed.

proper fingerstick

- Holding finger below the level of the heart in a dependent position, helps increase blood flow to the area, ensures adequate specimen for collection. - clean the finger with an antiseptic swab or with soap and water. allow the fingertip to dry completely. - puncture the side of the finger, avoiding sites beside bone. - wrap the finger in a warm cloth to increase blood flow to the area.

disposing biohazard materials to reduce the risk of transmission of microorganisms.

- Soiled linen placed in a single bag that is tightly secured - Chlorine bleach used to clean blood spills . - Empty blood bags returned to the blood bank in case a transfusion reaction occurs - used needles should not be broken or bent.

NURSING INTERVENTION: family centered care

- consider the health of the family as a unit; client and family members help determine their outcomes and goals. - Setup a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment - provide suggestions and offer support but should not make the final decision about changes to the care plan. - family must decide, with the nurse's input, what to do before the client goes home.

WOUND: tertiary intention

- includes using sutures to close an open wound at a later date after the wound drains and starts to heal. - provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing - skin grafting is required for deeper wounds such as full-thickness burns and is only rarely required for surgical wounds that do not heal.

NURSING INSTRUCTIONS: proper use of inhaler

- instruct to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly. - instruct to rinse the mouth with water following the use of the inhaler to reduce irritation and infection, not before using the inhaler. - instruct to wait 20 to 30 seconds between inhalations of bronchodilator medications such as albuterol. - instruct to place the inhaler in the mouth and tightly close the lips around the mouthpiece to create a seal, then depress the canister, take a deep breath, and hold it for at least 10 seconds.

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? A. Elevating the finger above heart level B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Wrapping the finger in a warm cloth

A. Elevating the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room. B. Evacuate the client from the room. C. Sound the fire alarm. D. Activate the fire extinguisher.

B. Evacuate the client from the room. The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. The components of RACE are rescue, activate, confine, and extinguish. - first priority is rescuing or removing the client from immediate danger. - second action is activation of the fire alarm system. - third action is confining the fire by closing doors and windows. - final action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to extinguish a fire could compromise the safety of clients or staff members, the nurse should await the arrival of emergency fire personnel.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold

B. Hold the linens away from the body and clothing The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms. - place the soiled linens in a linen bag immediately after removing the linen from the bed to prevent the spread of microorganisms on surfaces within the client's room and to minimize exposure to personnel. - Soiled linen is contaminated with microorganisms and will further contaminate the floor and attract any microorganisms present on the floor, which places the nurse and the client at risk of infection. D- Opening linens by shaking them causes movement of air. Air currents can carry dust and spread microorganisms throughout the room, which places the client and the nurse at risk of infection.

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required? A. "I should not leave all 4 side rails up unless there is a prescription for restraints." B. "An alert client will be safest if I raise the 2 upper side rails at the head of the bed." C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." D. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed."

C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." Raising all 4 side rails can put the client at greater risk for injury. For example, the client might try to climb over the side rails, which could result in a fall.

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures there are no kinks in the drainage tubing.

C. The AP hangs the collection bag at the level of the bladder. The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity. - cleanse the client's perineal area with soap and water at least 3 times per day to reduce the risk of infection. - tape the catheter to the inner thigh of a female client to prevent pulling on the urethra as the client moves around. When the catheter tugs and pulls on the urethra, it increases the risk of infection and of dislodging the catheter. - make sure there are no kinks in the tubing to ensure proper drainage by gravity.

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean blood spills. B. Discard empty blood bags in a bedside trash can. C. Break used needles before discarding. D. Place soiled linen in a single linen bag.

D. Place soiled linen in a single linen bag. Soiled linen should be placed in a single bag that is tightly secured to reduce the risk of transmission of microorganisms.

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure knot with the restraint straps B. Attach the restraints' straps to the bedside rails C. Make sure 3 fingers fit beneath the restraints D. Remove the restraints at least every 2 hr

D. Remove the restraints at least every 2 hr The nurse should remove the restraints at least every 2 hours to reposition the client, provide fluids and nutrients, assist with range-of-motion exercises, and evaluate the client's overall wellbeing. - The nurse must attach the restraint with a quick-release buckle or a knot that does not tighten when pulled. - make sure 2 fingers fit under the restraints.

bargaining stage of grief

During the bargaining stage of grief, a client stalls awareness of the loss by trying to keep it from occurring

How to obtain a pulse deficit?

assess the client's radial and apical pulses simultaneously and the compare both rates. To calculate: subtract the difference between the apical and radial pulse rates.

posterior tibial pulse location

located on the inner side of the ankle. - best felt with the client's foot relaxed and extended slightly.

Side Rails as Restraints

- Raising all 4 side rails can put the client at greater risk for injury. For example, the client might try to climb over the side rails, which could result in a fall. - Side rails are a form of restraint when all 4 rails are raised. This requires a prescription from the provider after less restrictive methods have been unsuccessful. - Leaving the 2 upper side rails up improves the client's ability to turn and move around in bed. The client will also be able to use the rails when getting out of bed, which will help prevent falls. - Raising all 4 side rails is not considered a restraint if the client is sedated. This action reduces the client's risk for injury due to falling out of bed.

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."

A. "Call me when you are ready, and I will return with the medication." The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration. - In an inpatient setting, the nurse is responsible for administering medication to the client. - If the nurse returns to the client's room in 30 minutes, the nurse will not be able to verify that the client took the medication since the client could have hidden or discarded the medication. - The nurse is responsible for administering the medication at the scheduled time, generally may be given within 1 hour of the prescribed time (i.e. ≤30 minutes prior to or ≤30 minutes after the prescribed time of administration).

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 min in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

A. Avoid beverages that contain caffeine Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages.

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the client's provider and verify the prescription D. Ask the client if she takes this medication at home

A. Consult the medication reference book available on the unit A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up in the medication reference on the unit. - information from this source is not sufficient to allow the nurse to administer the medication safely. - no reason to believe that the medication prescription is in error; not necessary to confirm w/ prescriber

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. D. Log-roll the client.

A. Lock the wheels on the bed and stretcher. Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed to move apart or away from the client. - ask the client to cross his arms across his chest to avoid injuring the arms during the transfer. - stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. D. Log-rolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit? A. Obtain the apical and radial rates simultaneously B. Check the blood pressure in the left and right arms C. Compare the pulse strength in the upper extremities D. Palpate the pulses in the lower extremities

A. Obtain the apical and radial rates simultaneously To assess for a pulse deficit, the nurse and a second person assess the client's radial and apical pulses simultaneously and the compare both rates. To calculate the pulse deficit, the nurse should subtract the difference between the apical and radial pulse rates. - check BP in both the left and right arms for a client who is experiencing a dysrhythmia, not for pulse deficit.

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage An ostomy bag full of blood indicates that the client's bowel is hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's circulation.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min B. Fill the bag 2/3 full with ice C. Place the ice bag uncovered on the client's ankle D. Tell the client that numbness is expected when the ice bag is in place

B. Fill the bag 2/3 full with ice The nurse should fill the bag two-thirds full with ice, which allows the bag to be molded around the client's ankle. - To reduce the risk of injury, leave the ice bag in place for no longer than 30 minutes. - cover the ice bag with a towel or other type of cover before placing onto skin. - remove the ice bag if feeling numbness = indication skin is too cold and at risk of injury.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back The nurse should use this technique to assess skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; in dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the forearm.

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A. Allows minimal treatment B. Benefits the client's family C. Offers hope for a cure D. Supports self-determination

D. Supports self-determination The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right.

NURSING ASSESSMENT - hypokalemia and hyperkalemia

Hypokalemia occurs when potassium is <3.5 mEq/L. - assess for muscle weakness and other clinical manifestations of hypokalemia C. Hyperkalemia occurs when potassium is >5.0 mEq/L. - assess the client for muscle weakness, cardiac dysthymias, and other clinical manifestations of hyperkalemia

Denial stage of grief

During the denial stage of grief, unable to accept the reality of the loss.

NURSING INTERVENTION: bleeding at the IV insertion

Bleeding at the IV insertion site might indicate the IV system is not intact. - should check to determine if the IV system is intact and if the catheter is within the client's vein. - might need to start a new IV line in another location if the bleeding does not stop after interventions.

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestines C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic illnesses

A. Decreased estrogen and testosterone production Both estrogen and testosterone levels start to decrease in middle age.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open C. Rinse the client's mouth with an alcohol-based mouthwash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges A. Place the client in a lateral position with the head turned to

A. Place the client in a lateral position with the head turned tothe side before beginning the procedure The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions. - use a padded tongue blade - use either water or alcohol-free mouthwash - use a foam swab because lemon-glycerin swabs dry and irritate the mouth and can damage the teeth.

A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown. B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.

A. Wear gloves when changing the client's gown. The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client in contact isolation. - use soap and water to cleanse the hands. Alcohol-based hand sanitizer is ineffective against the spores of C. difficile. - wear a mask when working within 3 feet of a client who has an infection, and droplet precautions are required. - do not place the client on complete bed rest because this places him at risk for the hazards of immobility, such as impaired skin integrity and retained respiratory secretions. The nurse should instruct the client to remain in his room but to move, cough, and deep breathe at least every 2 hours.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain

B. Encourage the client to express thoughts about death and dying The nurse should recognize the client's need to talk about impending death and encourage the client to discuss thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can encourage sharing when appropriate. If the nurse does not want to share personal beliefs, offering self and listening to the client's thoughts are appropriate.

A nurse is caring for a client who has a temperature of 38.7°C(101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day

B. Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering. Incorrect Answers:A. This therapy is no longer recommended as an intervention for a fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. - providing the client with at least 1893 mL (64 oz) of fluid per day.

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible click B. Murmur C. Third heart sound D. Pericardial friction rub

D. Pericardial friction rub A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound that is heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems like rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward.

the technique determine a client's body fat percentage

Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

the technique determine the extent of a client's pitting edema

Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression

autonomy

the ethical principle of autonomy involves ensuring the client has the right to make personal decisions.

justice

the ethical principle of justice involves treating everyone fairly.