ATI fundamentals semester 1

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process?

"Another nurse should listen to the phone call."

A nurse is caring for a client who requires a 24-hours urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00am and have saved all urine since." (for a 24-hours urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is preparing to administer digoxin to a client who states, "I don't want to take that medication. I do not want one more pill." Which of the following responses should the nurse make?

"Tell me your concerns about taking this medication?"

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"When descending stairs, I will first shift my weight to my right leg"

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old."

health care proxy

(also known as durable power of attorney for health care): A codument that appoints someone to make medical decisions when clients are no longer able to do so on their own behalf

A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding?

- "I will observe for adverse effects" - "I will monitor for therapeutic effects" - "I will refuse to give a medication if I believe it is unsafe"

A nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100?

- A once-daily multivitamin - A subcutaneous injection prescribed once weekly

A nurse is preparing to transfer a client who is 72 hours postoperative to a long-term care facility. Which of the following information should the nurse include in the transfer report?

- Advance directives status - Medical diagnosis - Need for specific equipment

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take?

- Apply fresh linens and place a clean gown on the body - Remove all equipment from the bedside - Dim the lights in the room (helps to provide a calm environment for the family)

A nurse is planning for care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

- Assist the client with a partial bed bath - Measure the client's BP after the nurse administers an antihypertensive medication - Use a communication board to ask what the client wants for lunch

A nurse if providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

- Check the cord routinely for frays or tearing - Consider purchasing a generator for power backup - Observe for signs of hypoxia

A nurse is assisting with the discharge planning for a client. Which of the following actions should the nurse take?

- Determine the client's need for home medical equipment - Obtain printed instructions for medication self-administration - Provide the family with a list of community agencies that can provide assistance - Discuss the importance of attending follow-up appointments

A nurse is caring for a client who had a stroke and is scheduled to transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility?

- Ensure that the client has possession of their valuables - Confirm that the rehabilitation center has a room available at the time of transfer - Give a verbal transfer report via telephone - Complete a transfer form for the receiving facility

A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure?

- Explains the roles of other care delivery staff - Begin discharge planning - Document the client's wishes about organ donation - Introduce the client to their roomate

Which of the following actions should then nurse take when demonstrating an empathetic presence to a client?

- Having an open posture, facing the client, and leaning forward are ways that can demonstrate an empathic presence - Establish and maintain eye contact - Sit facing the client

A home health nurse is assessing the safety of a client's home. The nurse should identify which of the following factors as increasing the client's risk for falls

- History of a previous fall - Reduced vision - Impaired memory - Kyphosis

A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber?

- Kidney beans - Blackberries - Whole grain cereals - Whole wheat bread

A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess?

- Muscular weakness in lower extremities - Unsteady, wide-based or waddling gait

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

- Place the client in a room with negative pressure airflow - Wear gloves when assisting the client with oral care - Use antimicrobial sanitizer for hand hygiene

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching?

- Provide extra time for completion of ADLs - Perform ROM exercises

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

- Pupil clarity - Visual fields - Visual acuity

A nurse who has just assumed the role of unit manager is examining her skills in interprofessional collaboration. Which of the following actions support interprofessional collaboration?

- Recognize the knowledge and skills of each member of the team - Encourage the client and family to participate in the team meeting - Support team members requests for referral

A nurse manager is observing the actions of a nurse they are supervising. Which of the following actions by the nurse requires the nurse manager to intervene?

- Reviewing the health care record of a client assigned to another nurse - Making a copy of a client's most current laboratory results for the provider during rounds (paper copies of confidential information create a risk for breach of confidentiality) - Providing information about a client's condition to hospital clergy - Participating in walking rounds that involve the exchange of client-related information outside clients' rooms (sharing information in the hallway where it can be overheard by others can result in a breach of confidentiality)

A nurse on an acute care unit is caring for a client following a total hip arthroplasty. The client is confused, moving the affected leg into positions that could dislocate the new hip joint, and repeatedly attempting to get out of bed. After determining that restraint application is indicated, which of the following actions should the nurse take?

- Secure the restraint to the frame of the bed - Get a prescription for restraints from the provider - Have a family member sign the consent for restraints - Tie the restraint to the side rail using a quick-release knot -

A nurse is preparing a client's medications. Which of the following actions should the nurse take in following legal practice guidelines?

- Teach the client about the medication - Monitor for adverse effects - Lock compartments for controlled substances

A nurse is assessing a client before administering medications. Which of the following data should the nurse obtain?

- Use of herbal products - Ability to swallow - Allergies

A nurse is planning to teach a client about a low potassium diet. Which of the following foods should the nurse instruct the client to avoid?

- Yogurt - Orange juice

effects of immobility metabolic

- altered endocrine system - decreased basal metabolic rate - changes in protein, carbohydrate, and fat metabolism - decreased appetite with altered nutritional intake - negative nitrogen balance - decreased protein resulting in loss of muscle - loss of weight - alterations in calcium, fluid, and electrolytes - reabsorption of calcium from bones - decreased urinary elimination of calcium, resulting in hypercalcemia

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development?

- apply elastic stockings - assist the client to change positions often

effects of immobility respiratory

- decrease respiratory movement resulting in decreased oxygenation and CO2 exchange - stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypostatic pneumonia - decreased cough response

ice therapy

- decreases inflammation, prevents swelling, reduces fever - do not use in patients with cold intolerance or vascular insufficiency - "On/Off" periods - do not place under someone who is immobile or with sensory impairments

effects of immobility integumentary

- increased pressure on skin, which is aggravated by metabolic changes - decreased circulation to tissue causing ischemia, which can lead to pressure injury

What are some seizure precautions?

- make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails. clients at high risk for generalized seizures should have a saline lock in place for immediate IV access. - ensure rapid intervention to maintain airway patency - inspect the client's environment for items that could cause injury during a seizure, and remove items that are not necessary for current treatment - assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury - advise all caregivers and family not to ut anything in the clients mouth during a seizer

effects of immobility cardiovascular

- orthostatic hypotension - less fluid volume in the circulatory system - stasis of blood in the legs - diminished autonomic response - decreased cardiac output, leading to poor cardiac effectiveness, which results in increased cardiac workload - increased oxygenation requirement - increased risk of thrombus development

Creatinine range

0.5 to 1.1 mg/dL for women 41-60 0.6 to 1.3 mg/dL for men 41-60

types of nociceptive pain

1. Somatic - bones, joints, muscle skins or connective tissue, and central nervous system 2. Visceral - in internal organs such as the stomach or intestines. It can cause referred pain in other other body locations not associated with the stimulus. 3. Cutaneous - in the skin or subcutaneous tissue

Urine Specific Gravity Normal Range

1.005 - 1.030 (Usually 1.010 - 1.025)

How far away must an oxygen tank be from open flames, such as a fireplace or a gas stove?

10 feet and 8 feet from other heat sources

angle for ID injection (such as tb or allergy testing

10-15 degrees

BUN range

10-20 mg/dL

What angle to use to an IV catheter?

10-30 degrees for older adults, 10-15 degrees

expected pulse rate for a 1-week-old infant

107-180/min

Sodium normal range

135-145 mEq/L

How much should a client with a hearing aid initially wear the device?

15-20 minutes a day and increase the time slowly to 10-12 hours each day

The nurse should consider objects contaminated if there are _______ from the border of the sterile field.

2.5 cm (1 in.)

How far/close should the shoulder rests on crutches be to the axillae?

2.5-5 cm (1-2 in.) below the axillae to avoid injury to the underlying nerves

how flexed should elbows be with crutches?

20* to 30*

Normal HCO3 range

22-26 mEq/L

FiO2 venturi mask

24% to 50% at flow rates of 4 to 12 L/min high-flow oxygen delivery systems delivers the most precise oxygen concentration with humidity added best for clients who have chronic lung disease

FiO2 nasal cannula

24-44% at flow rate of 1 to 6 L/min

normal potassium levels

3.5-5.0 mEq/L

How many mL are in an ounce?

30 mL

To obtain an accurate blood pressure measurement, how far past the point of last palpable pulse should the nurse inflate the cuff?

30 mmHg

FiO2 simple face mask

35% to 50% at flow rates of 6 to 12 L/min (minumum flow rate is 6 L/min to ensure flusion of CO2 from the mask)

Normal PCO2 range

35-45 mmHg

What size syringe should be used to irrigate the wound?

35-mL

angle for SQ injection (such as insulin or herparin)

45 to 90 obese 90

How far ahead of the client should they advance their crutches when walking?

6 inches in front and to the side of each foot

how far should the cane be from the body?

6 to 10 inches

FiO2 Partial Rebreather Mask

60% to 75% at flow rates of 6 to 11 L/min

Normal pH range

7.35-7.45

A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice creams (the nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.)

FiO2 of non-rebreather mask

80% to 95% at flow rates of 10 to 15 L/min delivers the highest O2 concentration possible (except for intubation)

angle of IM injection

90

Where should you set up the sterile field?

A clean area above waist level in the client's environment (a bedside stand)

Patient Self-Determination Act (PSDA)

A federal law that mandates that every individual has the right to make decisions regarding medical care, including the right to refuse treatment and the right-to-die; requires that all clients admitted to a health care facility be asked whether they have advance directives

Corticosteroids

A group of hormones, including cortisol, released by the adrenal glands at times of stress

A nurse is reviewing a client's prescribed medications. Which of the following situations represents a contraindication to medication administration?

A medication is approved for ages 12 and older, and the client is 8 years old.

What are the five rights of delegation?

A. Right task B. Right circumstance C. Right person D. Right direction or communication E. Right supervision

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping (since this client has hyponatremia, the manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen at least 2 inches from the umbilicus

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45* angle.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse inclulde?

Advocacy ensures clients' safety, health, and rights.

How often should you have a vision test?

Age 40 and under: every 3 to 5 years Every 2 years ages 40 to 64 Every year 65 and older

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative.

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan?

Apply a moist, nonadhering dressing is placed on the sac to keep it moist until surgery.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter.

nociceptive pain

Arises from damage to or inflammation of tissue other than that of the peripheral central nervous system. It is usually throbbing, aching, and localized this pain typically responds to opioids and nonopioid medications.

A nurse is preforming medication reconciliation with a client. Which of the following actions should the nurse take first?

Ask the client if she takes any over-the-counter medications

What is the nursing process?

Assessing Diagnosing Planning Implementing Evaluating

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds.

What is pernicious anemia?

Autoimmune destruction of parietal cells in the stomach, leading to loss of intrinsic factor and thus inability to take up vitamin B12

When inserting an IV, should the nurse place the extremity above or below the level of the client's heart?

Below the level of the client's heart to increase the dilation of the vein

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine (a client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.)

Systolic

Blood pressure in the arteries during contraction of the ventricles.

A nurse is preparing information fora change-of-shift report. Which of the following information should the nurse include in the report?

Bone scan scheduled for today

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds (when using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds)

When using a cane, should the client move their leg or the cane first?

Cane first by about 15 to 30 cm (6 inches to 1 foot) before taking a step with the weaker leg to maintain stability

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Check the pH of the client's stomach contents. (up to 5mL, less than pH of 5)

What disinfectant can kill spores?

Chlorine bleach

A nurse is preparing to insert a new IV catheter for a client. Which of the following actions should the nurse plan to take?

Choose a vein that is palpable and straight to limit the risk of infiltration.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received while at the facility

A nurse is caring for a client who is scheduled for surgery. The client hands the nurse information about advance directives and states, "Here, I don't need this. I am too young to worry about life-sustaining measures and what I want done for me." Which of the following actions should the nurse take?

Contact a client representative to talk with the client and offer additional information about the purposes of advance directives.

How often should a client or caregiver inspect oxygen equipment?

Daily

A nurse is caring for a client who is scheduled for a procedure. Prior to transporting the client for the procedure, the client states, "I don't understand the risks of having this procedure." Which of the following actions should the nurse take?

Delay the surgical procedure and notify the provider. (The nurse should advocate for the client by informing the surgical suite of the delay and notifying the client's provider. The provider should explain the risks and benefits of the procedure to the client.)

A nurse is caring for a young adult at a college health clinic. Which action should the nurse take first?

Determine the client's health risks

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet

What are the contact precautions for pharyngeal diptheria?

Droplet

A nurse is assessing an older adult during a home visit. Which of the following findings should the nurse report to the nursing supervisor?

Ecchymosis on the torso in various stages of healing, could be a possible indication of physical abuse.

How does anemia occur?

Either a reduction in the number of red blood cells (RBCs) or in hemoglobin, the oxygen-carrying component of blood. Can result from a decrease in RBC production, and increase in RBC destruction, or loss of blood.

hypercarbia

Elevated levels of CO2 • restlessness, hypertension, headache

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

Encourage the client to perform anti-embolic exercises every 2 hours

A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include?

Evaluate the toddler's need for an evaluation of hearing ability, because toddlers who have CP have an increased risk of hearing impairment

How often should the nurse assess vitals for a client with a PCA?

Every 1 to 2 hours during the first 12 hours, for they are at risk for respiratory depression as a result of opioid medication administration

How often should you have a dental assessment?

Every 6 months

How often should older adults have an eye exam?

Every year

A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include?

Family members should provide a code prior to receiving client health information Communication of client information can occur at the nurses' station A client can request a copy of their medical record A nurse can photocopy a client's medical record for transfer to another facility

What are some natural sources of Vitamin b12?

Fish, meat, poultry, eggs, milk

A nurse is preparing the discharge summary for a client who has had a knee arthoplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary?

Follow up care, instructions for diet and medications, contact information for the home health care agency

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?

For now, I should continue to have a mammogram each year. (the female client who is between the ages of 45 and 54 should have a mammogram annually)

How often should you have a physical examination?

Generally every 1 to 3 years for females and every 5 years for males from age 20 to 40, more often after age 40

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration to ensure the medication is mixed

What are some sources of folic acid?

Green leafy vegetables, dried peas and beans, seeds, orange juice, cereals and bread fortified with folic acid

A charge nurse is discussing the responsibility of nurses caring for clients who have a C. diff. infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which interventions should the nurse include?

Help the client see the benefits of their actions Identify the client's support systems Suggest and recommend community resources Teach stress management strategies

What position should the client be in when receiving an oral medication?

High-fowlers to reduce to the risk of aspiration

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which instructions should the nurse include?

Hold the cane on the right side Keep two points of support on the floor After advancing the cane, move the weaker leg forward The client should advance the stronger leg past the cane

Chvostek's sign

Hypocalcemia (facial muscle spasm upon tapping) numbness and tingling in the hands

A nurse is completing a dietary teaching with a client who has heart failure and has a prescription for a 2 g sodium diet. Which of the following statements made by the client indicated an understanding of the teaching?

I can have nonfat yogurt as a dessert (it is low in sodium and fat)

A nurse is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin. Which of the following actions should the nurse take first when mixing the solution?

Inject 25 units of air into the NPH vial of insulin.

NPH insulin

Intermediate-acting insulin Onset: 2-4hr, peak: 6-12 hr, 16-20 hr injected once to twice a day

What is the most common nutritional disorder in the world?

Iron deficiency anemia

dorsal recumbent

Lying on back, knees bent

What are some sources of iron?

Meat, fish, poultry, tofu, dried peas and beans, whole grains, dried fruit, iron-fortified foods (infant formula, infant cereal, ready-to-eat cereals)

A nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following conditions?

Metaboic alkalosis

A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances?

Metabolic alkalosis - A client who has influenza has experiences excessive vomiting leading to metabolic alkalosis. Manifestations include dizziness, Circumoral paresthesias, and numbness and tingling of the extremities

Can oxygen takes be on their side?

No, must be in an upright position to maintain safety.

Is evaluating a client's pain level within an AP's level of delegation?

No, this requires advanced nursing judgement

A nurse prepares an injection of morphine to administer to a client who reports pain, than asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the nurse take?

Offer to assist the client who needs the bedpan.

How should a client hold their crutches when sitting down?

One hand bar per hand

A nurse is performing an admission assessment for an older client. After gathering assessment data and performing the review of systems, which of the following actions is a priority for the nurse?

Orienting the client to their room

How often should you have a hearing test?

Periodic hearing checks as needed; more frequently if hearing loss is noted

What is the most common form of vitamin b12 deficiency?

Pernicious anemia

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear, this will help the medication get into the inner ear.

A nurse is caring for a client who has been sitting in a chair for one hour. Which of the following complications is the greatest risk to the client?

Pressure injury

heat therapy

Promotes vasodilation, decreases blood viscosity, increases metabolism of tissues, increases capillary permeability - should not be applied for longer than 20-30 minutes, or reflex vasoconstriction and tissue congestion can occur

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

How to move the ear when administering a medication to an otic adult?

Pull auricle upward and backward or upward and outward to straighten the ear canal.

Fire extinguishers PASS sequence

Pull the pin Aim at the base of the fire Squeeze the handle Sweep the extinguisher from side to side

A charge nurse is reviewing documentation with a gorup of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record?

Put the date and time on all entries Document objective data, leaving out opinions

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

How much sodium should a client with heart failure have as a max intake?

Reduce intake to less than 3,000 mg (3g) per day for mild-to-moderate heart failure and less thatn 2,000 mg/day for severe heart failure

A nurse is caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?

Reflecting

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate?

Repeat the details of the prescription back to the provider Have another nurse listen to the telephone prescription Obtain the provider's signature on the prescription within 24 hour

Fire response RACE

Rescue Alarm Contain/Confine Extinguish

if no Rh antigens present, the client it...

Rh-

What is a standard hand-off communication tool for nurses?

SBAR

A nurse is reviewing protocol in preparing for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

Brudzinski's sign

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed. An indication of meningeal irritation

How should clients clean their hearing aids?

Soft cloth, never soaking because water can damage it

How often should you have your blood cholesterol screened?

Starting at age 20, a minimum of every 5 years

How often should you have your blood glucose levels screened?

Starting at age 45, a minimum of every 3 yaers

Which comes first, sterile field or sterile gloves?

Sterile field

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's output.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30* to prevent aspiration of the enteral formula

stroke volume

The amount of blood ejected from the heart in one contraction.

A nurse is providing teaching to a client who has severe weakness in their right lower extremity and is learning to walk using a cane. Which of the following actions by the client indicates an understanding of the teaching?

The client moves the cane forward before taking a step.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client uses nonacetone nail polish remover because it is nonflammable.

During postmortem, should the nurse raise or lower the head of the bed?

The nurse should elevate the head of the client's bed to prevent blood from discoloring the client's face.

What joints should be exercised each session in active ROM? Same or different sets of joints?

The nurse should instruct the client to use the same sequence of movements to remember to exercise each muscle group.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has nosy respirations from secretions in their airway. Which of the following actions should the nurse take?

The nurse should turn the client at least once every 2 hours to break up the secretions in the client's lungs and prevent noisy respirations.

FiO2 (fraction of inspired oxygen)

The percent of O2 a client receives

Which side should the client hold their cane one?

The stronger side to obtain maximum support and correct body alignment

cardiac output

The volume of blood ejected from the left side of the heart in one minute. stroke volume x heart rate

How high should the nurse raise the bed when repositioning a client in bed?

To elbow level to bring the client close to the nurse's center of gravity

Packed Red Blood Cells (PRBCs)

To increase oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume

When performing active range-of-motion, how far should the joint go beyond the point of resistance?

To the point of resistance and not beyond to reduce the risk of injury

How many active ROM sessions should be performed a day?

Two

How much space should be between a compression sleeve and the skin?

Two fingers width

How often should ROM be provided with clients with immobiity?

Two to three times a day

When going down stairs, which leg should go first for someone using crutches?

Unaffected leg first.

What are some symptoms of an allergic reaction from a transfusion?

Urticaria, flushing of the face, and itching of skin

A nurse is planning to perform postmortem care for a client. Which of the following actions should the nurse plan to take?

Verify whether the client requires an autopsy before completing postmortem care or removing any indwelling lines, tubes, or catheters.

What vitamin facilitates the absorption of iron?

Vitamin C

When using a cane, which leg should be moved first - stronger or weaker?

Weaker leg

A nurse is caring for a client who has C. diff. infection. Which of the following actions should the nurse take?

Wear a cover gown when caring for the client.

When should the nurse notify the provider in regards to urinary output?

When it is less than 30 mL/hr

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precaution should the nurse take?

Wrap monitoring cords with stockinette and tape them in place.

Is baking soda high in sodium?

Yes

Can kypohosis cause a client at risk for falls?

Yes, because it alters the client's posture and center of balance.

Does a client with C. diff. require a private room?

Yes, but it does not need a negative airflow system.

what technique should be used for IM injections?

Z-track, prevents medication from leaking back

dosimeter

a badge that records exposure to radiation that is worn when taking x-rays

Baclofen (Lioresal)

a centrally acting skeletal muscle relaxant that decreases muscle spasm and severe spasticity

Juvenile Idiopathic Arthritis (JIA)

a chronic arthritic condition affecting the joints that occurs before 16 years of age

Nonmaleficence

a commitment to do no harm (i.e. when a patient needs a medication to relieve a symptom, however, in order to relive a symptom, the nurse may cause discomfort)

veracity

a commitment to tell the truth

Prednisone

a corticosteroid that increases muscle strength for children who have muscular dystrophy. It decreases inflammation in children tho have JIA

Methotrexate

a cytotoxic disease-modifying antirheumatic drug that slows joint degeneration and progression of rheumatoid arthritis. It is used for children who have juvenile idiopathic arthritis

necessary loss

a loss related to a change that is part of the cycle of life and is anticipated but still can be intensely felt. This loss can be replaced by something different or better e.g. first breakup

aerosol mask

a mask in which oxygen is humidified by aerosolized saline is given to a patient

complicated grief

a person has a prolonged or significantly difficult time moving forward after a loss difficult progression through the expected stages can develop suicidal ideation, intense feelings of guilt, lowered self-esteem somatic complaints persist for an extended period of time

contact precautions

a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies

Droplet precautions

a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis

Airborne precautions

a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles

friction rub

a scratching or squeaking sound that persists throughout the respiratory cycle

Diazepam (Valium)

a skeletal muscle relaxant that decreases muscle spasms and sever spasticity

stupor

a state of near-unconsciousness or insensibility

common sites for SQ injections

abdomen, upper hips, lateral upper arms, thighs

Manifestations of hyponatremia

abdominal cramping, weakness, confusion, lethargy, headache, nausea, tachycardia

neuropathic pain

abnormal processing of pain message; burning, shooting in nature i.e. phantom limb pain

is sterile above or at waist level?

above waist level

beneficence

action that promotes good for others, without any self-interest (i.e. advocating for a patient's needs, caring for a difficult patient, etc)

pneumothorax

air in the pleural cavity

disenfranchised grief

an experienced loss that cannot be publicly shared or is not socially acceptable (suicide, abortion, overdose)

oxybutynin

antispasmodic, anticholinergic medication that decreases bladder spasms

maturational or developmental loss

any loss normally expected due to the developmental processes of life. These losses are associated with normal life transitions and help people develop coping skills e.g. a child leaving home for college, dad giving away daughter at wedding

actual loss

any loss of a valued person, item, or status (loss of a job) that others can recognize e.g. loss of body part

situtational loss

any unanticipated loss caused by an external event e.g. a family loses their home during tornado, automobile accident leaves driver paralyzed

perceived loss

anything client define as loss but that is not obvious or verifiable to others, easily overlooked or misunderstood because the loss is individual to the client e.g. losing your 4.0 GPA

NSAIDS examples

aspirin (Ecotrin), ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve) (nonsteroidal anti-inflammatory drugs)

Romberg test

assesses ability of vestibular apparatus in inner ear to help maintain standing balance

platelets function

blood clotting

What should irrigation solution be warmed to?

body temperature

Ecchymosis

bruising

ginkgo biloba

can be taken to improve memory and reduce stress

valerian and chamomile

can be taken to reduce anxiety

manifestations of hyperkalemia

cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, GI manifestations

HIPAA

client privacy and confidentiality

Who is most at risk for a latex allergy?

clients with spina bifida and multiple surgeries

atelectasis

collapsed lung

cerebral palsy (CP)

condition characterized by lack of muscle control and partial paralysis, caused by a brain defect or lesion present at birth or shortly after

normal grief

considered uncomplicated may include anger, resentment, withdrawal, hopelessness, and guilt, should move toward acceptance some acceptance should be evident by 6 months after the loss somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue

should the client have cotton or synthetic fabrics when using oxygen?

cotton because synthetic or wool fabrics can generate electricity

therapeutic effects of cold

decreases inflammation prevents swelling reduces bleeding reduces fever diminishes muscle spasms decreases pain by decreasing the velocity of nerve conduction

hyperventilation

deep breathing pattern with an increased rate; leads to decreased levels of carbon dioxide and hyperoxygenation

5 stages of grief (kübler-ross model)

denial, anger, bargaining, depression, acceptance

nebulizer

device that creates a mist used to deliver medication for giving respiratory treatment

living will

directive documents for medical treatment per clients' wishes (a type of advance directive)

crackles

discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways

The Patient Care Partnership

document developed to ensure fairness and effectiveness of the health care system; addresses clients' rights when receiving care

rhonchi

dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions

when should a nurse collect sputum specimens?

early in the morning

How often to instruct client to deep breathe to reduce the risk of atelectasis?

every 1 to 2 hours

How often to reposition a client to reduce the risk for pressure injuries?

every 1 to 2 hours

How often should an older adult receive a tetanus booster?

every 10 years

How often should you have your blood pressure assessed?

every 2 years, annually if previously elevated

How often should you have a skin assessment?

every 3 years by a specialist for age 20 to 40 annually for > 40 years old

How often should an adult of age 50 have a fecal occult blood test done?

every year for clients who are at average risk

anticipatory loss

experienced before the loss happens e.g. person recieves a terminal diagnosis and begins the process of saying goodbye.

justice

fairness in care delivery and use of resources

Manifestations of hypokalemia

fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness and cramps, paresthesias, glucose intolerance, decreased muscle strength, DTRs

digital rectal examination (DRE)

finger palpation through the anal canal and rectum to examine the prostate gland

protective equipment precautions

for clients who have a compromised immune system , such as those who have had an allogeneic hematopoietic stem cell transplant

fidelity

fulfillment of promises

muscular dystrophy

group of hereditary diseases characterized by degeneration of muscle and weakness

Allogeneic hematologic stem cell transplants

healthy bone marrow cells are harvested from a donor who has a matching tissue type to the recipient

respiratory alkalosis

high pH, low bicarbonate tremulousness, blurred vision, difficulty concentrating

urticaria

hives

What does quality of pain refer to?

how the pain feels; sharp, dull, aching

Numbness of the extremities is a manifestation of...

hyperkalemia

anticipatory grief

implies the "letting-go" of an object or person before the loss, as in case of terminal illness individuals have the opportunity to start the grieving process before the actual loss

What can a whistling sound indicate with hearing aids?

incorrect insertion of the hearing aid, improper fit, or ear wax build-up

kussmaul respirations

increased respiratory rate, regular pattern, but abnormally deep

therapeutic effects of heat

increases blood flow increases tissue metabolism relaxes muscles eases joint stiffness and pain

whole blood: expected pharmacological action

increases circulating blood volume

thrombophlebitis

inflammation of a vein associated with a clot formation

the medication reconciliation process

involved identifying and addressing the duplication and/or omission of medications as well as checking for possible interactions among them

Cheyne-Stokes respiration

irregular rate and depth of respirations that follow a cyclical pattern. the client will experience shallow breaths that progress to a normal pattern, and increased rate, then rate begins to slow again, ending with an apneic period

fecal occult blood test

lab test performed to detect blood in the feces

advance directives

legal documents that direct end-of-life issues

Systolic normal range

less than 120

diastolic normal range

less than 80

manifestations of metabolic acidosis

low pH level and a low bicarbonate level Kussmaul's respirations, lethargy, confusion

respiratory acidosis

low pH, high bicarbonate warm, flushed skin, headache, tachycardia

Rosuvastatin function

lower cholesterol

supine

lying on the back, head and shoulders elevated on a pillow and forearms on pillow or at their side

Myelomeningocele (spina bifida)

most severe form of spina bifida in which the spinal cord and meninges protrude through the spine

max size of an endotracheal suctioning?

no larger than a 15 French suction catheter when suctioning an 8mm endotracheal tube or tracheostomy tube

Is an alcohol-based antiseptic solution effective against spores?

no, use nonantimicrobial soap and water

eupnea

normal breathing

What is the pH of stomach acid?

normally 1.5-3.5, must be under 5 to confirm gastric placement

transmission of pain

occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it

Platelet concentrate

platelets removed from unrefrigerated fresh whole blood and stored for transfusion

hypostatic pneumonia

pneumonia that usually results from the collection of fluid in the dorsal region of the lungs and occurs especially in those (as the bedridden or elderly) confined to a supine position for extended periods

modulation of pain

process by which the sensation of pain is inhibited or modified

What is the function of folic acid?

production of RBC's and growth and development

Albumin

protein in blood; maintains the proper amount of water in the blood

surgical asepsis

refers to the use of precise practices to eliminate all micro-organisms from an object or area and prevent contamination ("sterile technique"). applies to parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures

medical asepsis

refers to the use of precise practices to reduce the number, growth, and spread of micro-organisms ("clean technique"). it applies to administering oral medication, managing nasogastric tubes, providing personal hygiene, and performing many other common nursing tasks

overdose

respiratory acidosis

what can be an affect of long-term oxygen therapy?

respiratory alkalosis

Paraphrasing

restates the client's feelings for them to confirm what they have been communicated.

hypoventilation

shallow breathing pattern with an abnormally low rate

Regular insulin

short acting insulin 30 minutes after injection, peaks in 2 to 3 hours, and keeps working for up to 8 hours

Which diabetes medication is drawn up first?

short-acting, this prevents the possibility of accidentally injecting some of the longer-acting insulin into the shorter-acting insulin vial

How far apart should the nurse's feet be from each other when repositioning a client in bed?

shoulder-width apart to increase stability and reduce the risk for injury

How often should you have a tuberclulosis screen?

skin test every 2 years, health care workers should be screened annually

What should the client with a hearing aid place their volume at upon insertion?

slowly to one-third and one-half volume

Client pathways

specific to a client diagnosis and show the average length of stay a client with the diagnosis will have; a projection of treatments the client will receive

echinacea

stimulates immune system reduces risk of infection

which side should the cane be one, weak or strong?

strong

what are some late manifestations of hypoxia?

stupor, cyanotic skin, mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysrhythmias

What kind of injection does heparin involve?

subcutaneous

is pain objective or subjective data?

subjective

dependent position

supported

What are some early manifestations of hypoxia?

tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin, mucous membranes, elevated blood pressure, use of accessory muscles, nasal flaring, adventitious lung sounds

feverfew

taken to promote wound healing and decrease inflammation associated with arthritis

asepsis

the absence of illness-producing micro-organisms. hand hygiene is the primary behavior

acceptance

the client acknowledges what is happening and plans for the future by moving forward

anger

the client directs anger towards the self, others, a deity, objects, or the current circumstances

denial

the client has difficult in believing an expected or actual loss

depression

the client is overwhelmingly saddened by the inability to change the situation

prone

the client lies flat on their abdomen and chest with the head to one side and back in correct alignment

bargaining

the client negotiates for more time or a cure

transduction of pain

the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors)

pulse pressure

the difference between the systolic and the diastolic pressure readings

diffusion

the exchange of oxygen and CO2 between the alveoli and the red blood cells. measure the diffusion with pulse oximetry

ventilation

the exchange of oxygen and carbon dioxide in the lungs through inspiration and expiration. measure ventilation with the respiratory rate, rhythm, and depth

perfusion

the flow of red blood cells to and from the pulmonary capillaries. measure perfusion with pulse oximetry

What can RNs not delegate?

the nursing process client education tasks that require clinical judgment (for those that are not also RN's)

incident (incident report)

the occurrence of an accident or an unusual event. e.g., medication errors, falls, omission of prescription, needlesticks

pain threshold

the point at which a person feels pain

autonomy

the right to make one's own personal decisions, even when those decisions might not be in that person's own best interest

which leg moves first with a cane?

the weaker leg

common sites for ID injections

thin-skinned, hairless sites such as the inner surface of the mid-forearm or the scapular area of the back

manifestations of hypernatremia

thirst dry, sticky mucous membranes altered mental satus-restlesness, decreased level of conciousness muscle twitching seizures

How many exercises per session should happen in active range-of-motion?

three each session to reduce the risk of injury

An important factor when lifting heavy objects is...

tighten the abdominal muscles to increase support to the back muscles

Why withdraw NPH insulin before regular insulin in a circumstance of needing both?

to prevent contamination of the rapid-acting regular insulin with the intermediate-acting NPH insulin

nursing actions for airway management

use the lowest level of oxygen necessary to maintain an adequate SpO2 monitor ABGs and notify the provider if SpO2 levels are outside the expected reference range decrease the FiO2 as the client's SpO2 improves

Restating

uses the client's exact words

common sites for IM injections

ventrogluteal, deltoid, and vastus lateralis (pediatric). dorsogluteal is no longer recommened as a common injection site due to its close proximity to the sciatic nerve

How does a pulse oximeter work?

via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood

Relief for joint pain

warm compresses or moist packs

What does ketones in the urine indicate?

• Uncontrolled DIABETES - poor glucose control • Alcoholism • Fasting - starvation • High protein diet - low CHO - Atkin's diet • Febrile illness - esp. infants & children