CASAL OA REVIEW

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.

(C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct Answer: C

What methods can be used to determine proper placement of NG tube?

- Chest x-ray - assessing the pH of gastric contents - Listening for air in the stomach

What is the main objective of hospice care? (2)

- Enhance the client's life - ensuring the client's pain is managed

ABCDE Principles:

- airway - breathing - circulation - disability - exposure

Clients that are allergic to latex are usually allergic to: (3)

- bananas - avocados - kiwi

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.

1 A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis. Ph-7.35-7.45 PCO2 - 35-45 HCO3 - 22-30

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications

1 Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?

1,4 Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.

Chain of Infection: (5)

1. Causative Agent 2. Portal of Entry 3. Reservoir 4. Mode of Transmission 5. Portal of Exit

Locations for blood glucose sticks: (5)

1. earlobe 2. heel 3. palm 4. arm 5. thigh

hours to avoid the sun

10am to 4pm

Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.

15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B). Correct Answer: B

1 tablespoon (tbsp) to mL

15 mL

How long do you wash hands?

15 seconds

IV sizes (3)

16= TRAUMA PT 18-20 = SURGERY OR RECEIVING BLOOD PTs 22-24 = other pts

A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? 1 Excessive carbohydrate intake 2 Lack of protein supplementation 3 Insufficient intake of water-soluble vitamins 4 Increased concentration of electrolytes in cells

2 An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin

2 The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1 Stimulating the urge to defecate. 2 Lubricating the sigmoid colon and rectum. 3 Dissolving the feces. 4 Softening the feces

2 The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.

How long do you wash soiled hands?

2 minutes

1 kg to lbs

2.2 lbs

How of the heart is on the left of midline?

2/3

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis

3 Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer

3 Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1 Respiratory rate. 2 Amount of oxygen in the blood. 3 Percentage of hemoglobin-carrying oxygen. 4 Amount of carbon dioxide in the blood

3 The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.

Patients should be raised to __ degrees when using fracture pan

30

Class 2 (yellow tag)

30 TO 40 MINS CAN WAIT NOT LIFE THREATENING BUT NEEDS ATTENTION SOON

When should diabetic patients get their regular insulin injection?

30 minutes before they eat breakfast

1 oz to mL

30 ml

sit on the toilet -

30mins after eating to promote BM

A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.

4

normal gastric content PH

4

A client has been diagnosed as brain dead. The nurse understands that this means that the client has: 1 No spontaneous reflexes 2 Shallow and slow breathing 3 No cortical functioning with some reflex breathing 4 Deep tendon reflexes only and no independent breathing

4 A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of brain dead.

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1 6 hours 2 12 hours 3 18 hours 4 24 hours

4 After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)

4 Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 1 4 to 8 hours 2 12 to 24 hours 3 24 to 48 hours 4 72 to 96 hours

4 Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? 1 Prolonged use can cause dark concentrated urine. 2 The medication is best absorbed when taken on an empty stomach. 3 Take the medication with aluminum hydroxide to minimize GI upset. 4 Drinking alcohol daily can cause drug-induced hepatitis

4 Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression 4 Acceptance

4 In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall

4 Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention

A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1 Ask the client if he is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe

4 Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe

age to start oral temp

4 yrs

Enteral feeding via NG tube should be checked every ____ for gastric residual

4-6 hours

Width of the BP cuff should be approximately -

40% circumference of the extremity being used

BP cuff width

40% of upper arm circumference

When does menopause typically occur?

45-60 years of age

Patients should place canes __ inches in front of their feet before advancing

6 - 10 inches

1 gram to mg

60 mg

start asking child pain scale at age

7

To avoid combustion of oxygen, leave ____ ft from heat source

8

Chloride normal range

98-106

When does Ramadan occur?

9th lunar month

While assessing an adult client, the nurse identifies generalized edema in the client's arms, legs, and periorbital regions. Which dietary influence could have contributed to this generalized edema? A diet high in carbohydrates. A diet high in glucose. A diet low in protein. A diet low in sodium.

A diet low in protein. Rationale Proteins create great colloid osmotic pressure. If there is a protein deficiency then less fluid is reabsorb by the capillaries and the fluid remains in the interstitial tissue causing the edema.

Medicare

A federal program of health insurance for persons 65 years of age and older

stidor

A high-pitched sound caused by obstruction of the air passageway

AGONIST

A medication that causes stimulation of receptors.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.

A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care. Correct Answer: C

Crede's Method

A technique for promoting the expulsion of urine by manual compression of the bladder through pressure on the lower abdominal wall

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units

A) 11,000 units

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery?

A) What is your daily calorie consumption? Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference

Fat souble vitamins include: (4)

A, D, E, K

5 levels of consciousness

Alert Lethargic Obtunded Stupor Coma

perceived loss

Any loss defined by a client that is not obvious to others

The most effective management of pain is achieved using a(n) ___ schedule.

Around-the-clock

What technique is used for suctioning the trachea?

Aseptic

water soluble vitamins (2)

B and C COMPLEX

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets.

C) 1½ tablets

Reverse Trendelenburg's position

Entire bed frame tilted with foot of bed down. Used TO Promotes gastric emptying and prevents esophageal reflux.

Vitamin K

Helps blood clot

What position will help decrease intracranial pressure?

High fowler's position

CLASS 1 ( RED TAG)

IMMEDIATE THREAT TO LIFE

Which factors are most likely to decrease a client's perception of pain? Internal sense of control. Increasing levels of anxiety. Emotional and physical fatigue. The biological response to exercise. Positive previous experience managing pain.

Internal sense of control. The biological response to exercise. Positive previous experience managing pain. Rationale A person who possesses "internal locus of control" believes that they themselves have control over events in their lives and they can control and manage the outcome of their pain. Exercise causes an increase level of the release of endorphins which helps relieve pain and increases feeling of euphoria. If previous experiences of pain was adequately managed and relieved then present pain will be less anxious and scary.

The nurse is administering a skin test for allergies. Which type of injection should the nurse use? Intradermal. Intravenous. Subcutaneous. Intramuscular.

Intradermal. Rationale The allergens used for testing are so potentially potent, they are injected into the dermis where the blood supply is limited and drug absorption occurs more slowly. An anaphylactic reaction could occur if allergena are absorbed too rapidly.

Jewish patients follow what type of diet? (Judaism)

Kosher

maturational loss

LOSS EXPECTED WITH NORMAL LIFE TRANSITIONS (EX. KIDS LEAVING HOME TO COLLEGE)

The nurse is evaluating lab results in the client's electronic medical record. Which lab value may indicate a state of malnutrition? Low level of sodium. Low level of albumin. Low level of hemoglobin. Low level of magnesium.

Low level of albumin. Rationale Low level of albumin may indicate malnutrition.

Disease in blood vessels, in SMALLER (eyes, diabetic retinapothy)

Microangiopathy

CLASS 4 ( BLACK TAG )

NO CHANCE TO LIVE

What is the ICN definition of nursing?

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, & communities, sick or well in all settings.

Once digested, what percentage of carbohydrates is converted to glucose

Once digested, 100% of carbohydrates are converted to glucose. However, approximately 40% of protein foods are also converted to glucose, but this has minimal effect on blood glucose levels

PSYCHOMOTOR LEARNING DOMAIN focuses on:

PHYSICAL SKILLS ( COORDINATION, MOVEMENT, MANIPULATION)

Spontaneous Pain

Pain that is unpredictable and not associated with any activity or event

What is the best position that provides the best pressure relief over the sacral bony prominence?

Prone position using a small pillow below the diaphragm

Which electrolyte has a direct effect on a client's blood pressure? Sodium. Potassium. Calcium. Magnesium.

Sodium. Rationale Vascular volume is affected by the amount of sodium present which in turns affects the blood pressure. Sodium has an osmotic attraction to water. This increases circulating volume and thus blood pressure.

Autonomy =

Standing alone; independence; right to self-determination

incontinence

THE DIMINISHING OF ESTROGEN IN A WOMEN AFTER MENOPAUSE CAN CAUSE THIS

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Correct Answer: B

Evisceration

The displacement of organs outside of the body

Power of attorney for health care

The patient appoints a person (called a proxy or agent) to make health care decisions should the patient be unable to do so

Who defines the legal scope of practice for nursing?

The state board of a specific state.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 faint, barely detectable. 2 slightly weak, palpable. 3 normal. 4 bounding.

The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 + indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.

What are some patient rights? (6)

To see and copy their health record. To update their health record. To request correction of any mistakes. To get a list of disclosures. To request restrictions on certain uses or disclosures. To choose how to receive health information

What techniques should a nurse use when communicating with a severely withdrawn client? Use statements in which the nurse is making observations. Employ therapeutic touch and have client maintain eye contact. Speak slowly and ask questions using simple and concrete words. Display an encouraging and enthusiastic attitude when with client. Give the client plenty of time to respond to questions being asked.

Use statements in which the nurse is making observations. Speak slowly and ask questions using simple and concrete words. Give the client plenty of time to respond to questions being asked. Rationale Pointing out observations of the environment draws the client into and reinforces reality. Withdrawn clients may be thinking slowly and having difficulty comprehending. Withdrawn clients need time to process information and may need time to respond.

What is the primary treatment for S. aureus and MRSA

Vancomycin

ICE CHIPS weighs how much

WEIGH HALF OF THEIR WEIGHT EX: 8 OZ IS 4 OZ

role strain

WHEN ONES FEELS INADEQUATE FOR ASSUMING A ROLE

Trendelenburg position

WHOLE BED IS TILTED WITH HOB LOWER THAN FOOT OF BED , PROMOTES VENOUS RETURN

What is a natural laxative that stimulates peristalsis?

Warm prune juice

Moral Distress

When the nurse knows the right thing to do but either personal or institutional factors make it difficult to do the right thing.

What type of gauze is used to absorb exudate from a wound?

Woven gauze

living will

a document in which a person states his or her wishes about life support and other treatments IF SHE BECOMES INCAPACITATED

Durable Power of Attorney

a legal agreement that allows an agent or representative of the patient to act on behalf of the patient

Compartmentalization is when

a person appears to completely understand the existing circumstances, yet acts in a manner that does not correlate appropriately with reality.

role overload

a state in which too many expectations or demands are placed on a person

hypoxemia

abnormally low level of oxygen in the blood.

concomitant

accompanying

When does discharge planning start?

admission

Chamomile benefit:

anti-inflammatory, calming

Zinc Oxide is used for?

barrier cream intended for prevention measures usually used for a stage 1 ulcer and diaper rash

When should the NG tube be flushed when medication is administered?

before, after, and in between

Abnormal heart sounds are best heard

bell of the stethoscope

Beneficence means

benefit the patient

What should the suction pressure be? mmHg

between 80 to 120 mmHg

Ultrasound detects

bladder abnormalities and / or residual urine

Valsalva Maneuver

caused by bearing down or straining during a bowel movement

aspiration pneumonia

caused by foreign matter that is inhaled into the lungs

Buccal

cheek area " DON'T EAT OR DRINK UNTIL MEDS ARE DISSOLVED"

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

ethical dilemma

decision-making problem between two possible moral imperatives, neither of which is acceptable or preferable.

hyperosmolar imbalance

dehydration / water volume deficit

Kubler-Ross Stages (5)

denial, anger, bargaining, depression, acceptance

What part of the hand is best for assessing vibrations?

palmar surface

AD

right ear

Orthopedic position

sitting up and leaning over a table to breathe. good for pt with copd.

Tenacious

sticky

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.

(B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct Answer: B

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B

Native Americans sometimes feel that the cause of their illness are: (2)

- Evil spirit - Witch craft

Health care is paid by 3 major sources:

- Government: medicare and medicaid - Private health insurance - Out of pocket

BMI ranges: (3)

- Obese: 30 < - Overweight: 25 - 30 - Normal: 18 - 24

Pudding Benefits: (3)

- easy to swallow - provides calories and protein - require minimal chewing effort

Factors that increase body temperature:

- hormonal changes - exercise - dehydration - illness - food - fluids - smoking

During a seizing episode, (3)

- lower pt to floor or bed - turn pt on their side - lossen restrictive clothes

Nurses can entrust LPN for: (6)

- medication administration - enteral feedings - urinary catheter insertion - suctioning - trachea care - reinforcement of pt teaching

Islam Restrictions: (5)

- no alcohol - no pork - fasting during Ramadan - women must have female providers - pray 5x a day

Kosher diet (4)

- no shellfish - no meat and milk together - only fish with fins and scales - no pork

When a licensed nurse is moving from one state to another: (3)

- notify the previous state board of change of address - review the nurse practice act and practice guidelines in the new state - seek permission from the new state board to work as a nurse

Adjunct medications is used to treat: (3)

- seizure - anxiety - pain management

complicated grief

-a person has a prolonged or significantly difficult time moving forward after a loss. -INTERFERES WITH NORMAL FUNCTION OF LIFE -NO ACCEPTANCE AFTER 6 MONTHS

restraint must include (5)

-reason -how long -type -location -type of behavior that warrants the restraints

sanguineous drainage

-red,bloody ( serum + rbcs) - thick and appears reddish

post-menopausal women expected findings: (3)

-smaller nipples -more pendulous -nipple inversion

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1 If the client is allowed to give consent 2 The client cannot make informed decisions about health care. 3 If the client is permitted to give voluntary consent when parents are not available 4 The client probably will be unable to choose between alternatives when asked to consent

1 A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

episodic database focuses on

1 problem or complex or system

PPE includes: (6)

1. Gloves 2. Mask 3. Goggles 4. Face shields 5. Gowns 6. Caps

Stages of Infection (5)

1. Incubation 2. Prodromal 3. Illness 4. Decline 5. Convalescence

3 stages of inflammation:

1. Pain at the site of injury 2. WBCs kill microorganisms 3. Damage tissue is replaced by scar tissue

Reduce dietary sodium to less than ___ mg

2300 mg

Bladder of the cuff should be approximately -

60 - 80% of the circumference of the extremity being used

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated. Correct Answer: B

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B

Self-adhesive, transparent film

A temporary "second skin" ideal for small, superficial wounds

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.

A) Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

A) Be sure to have a complete physical examination before beginning your planned exercise program The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A).

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A) It is important that you continue your medication while learning to meditate. B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C) Obtain your healthcare provider's permission before starting meditation. D) Complementary therapy and western medicine can be effective for you.

A) It is important that you continue your medication while learning to meditate The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured

What are the steps of the nursing process? (6)

ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE DOCUMENT

What is the best way to restore strength

Active ROM

What nursing interventions should be implemented for a client whose absolute neutrophil count (ANC) is below 500? Admit to a reverse isolation room. Begin bleeding precaution protocol. Caution against any cut flowers in client's room. Screen and limit individuals wishing to visit. Provide only fresh organic fruits and vegetables.

Admit to a reverse isolation room. Screen and limit individuals wishing to visit. Caution against any cut flowers in client's room. Rationale The client has neutropenia and is at risk for infection. A reverse isolation, positive pressure room is the best choice for these clients. Cut flowers and live plants, along with fruits and vegetables have been shown to carry organisms that could cause harm to the immuno-compromised client. Visitors of these clients need to be limited and screen for possible signs of infection which could be lethal to an immuno-compromised client.

In a nutshell, the ICN's key values of nursing are:

Advocacy, promotion of a safe environment, research, education, and participation in shaping health policy and in patient and health systems management.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D). Correct Answer: A

Tripod position

An upright position in which the patient leans forward onto two arms stretched forward

In an adult client, which pulse should the nurse assess to determine if there is a pulse discrepancy or pulse deficit with the radial pulse? Apical. Brachial. Femoral. Popliteal.

Apical Rationale Pulse deficit should be completed by two nurses at the same time, one counting the radial pulse while the other is counting the apical.

Which statements are accurate about the nurse's use of an automated medication dispensing system? Select all that apply It ensures that the nurse administers the right medication to the right client. As medications are dispensed the system records and charges medications to the client. It is designed to help reduce the amount of medication errors made by a nurse. These systems are capable of verifying the appropriateness of client's medications. It logs the time, client, and medication each time the nurse accesses the system.

As medications are dispensed the system records and charges medications to the client. It is designed to help reduce the amount of medication errors made by a nurse. It logs the time, client, and medication each time the nurse accesses the system. Rationale Automated medication dispensing systems (AMDS) within a health care facility are networked with each other and with other computer systems in the facility to help record and charge the client. AMDS control the dispensing of medications and keeps track of the individual accessing the machine, client and the medication type, dose and time. The system is designed to help prevent medication errors, but it still requires a nurse to do the six rights of medication administration and review and check for appropriateness of medication for the client's condition.

Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets.

B) 1 tablet 15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B).

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.

B) 1.5 ml

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A) 13 ml/hour. B) 63 ml/hour. C) 80 ml/hour. D) 125 ml/hour

B) 63 ml/hour

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.

B) 8 a.m., 4 p.m., and midnight Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer.

B) A lactating woman nursing her 3-day-old infant A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.

B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Autopsy of the body is prohibited. B) Blood transfusions are forbidden. C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed

B) Blood transfusions are forbidden Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B).

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors

B) Nutritional history Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A) Irrigate the nasogastric tube with sterile normal saline. B) Reposition the client on her side. C) Advance the nasogastric tube an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use.

B) Reposition the client on her side The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet

B) Upper torso The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer.

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A) 42 gtt/min. B) 83 gtt/min. C) 125 gtt/min. D) 250 gtt/min

B. 83 gtt/min

Infection somewhere in the nasal or oral cavity or deep in the lungs can be the source of?

Bad breathe

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). Correct Answer: A

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct Answer: B

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement. Correct Answer: C

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.

C) Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private.

C) Acknowledge the client's distress and tell her it is all right to cry Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint. D) Change in the circumference of the joint in centimeters

C) Degree of flexion and extension of the client's knee joint The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.

C) Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. (A,B, and D)

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified

C) Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.

C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment. B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices.

C) Many complimentary healing practices can be used in conjunction with conventional practices Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A) asks relevant questions regarding the dressing change. B) states he will be able to complete the wound care regimen. C) demonstrates the wound care procedure correctly. D) has all the necessary supplies for wound care.

C) demonstrates the wound care procedure correctly A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first. Correct Answer: B

Which factors are most important in determining a client's health literacy? Can complete a client health care history form. Has ability to make necessary medical appointments. Has graduated from high school and has extensive life experiences. Shows financial independence and ability to pay for health care. Demonstrates ability to read and select credible health information.

Can complete a client health care history form. Has ability to make necessary medical appointments. Demonstrates ability to read and select credible health information. Rationale According to the Healthy People 2020 initiative, some of the factors the nurse should assess are a client's ability to make the necessary medical appointments, to read and identify credible health information and advocate for the appropriate medical care to determine their health literacy.

idiopathic pain

Chronic pain with UNKNOWN ORIGIN OFTEN ASSOCIATED WITH DEPRESSION

Which client behavior indicates to the nurse the client who is most likely proficient in health literacy? Client requests that the nurse read the information aloud as they left their glasses at home. Client questions the healthcare provider about their prescribed plan of care. Client is nonadherent with medication and recommended treatment plan of care. Client insists on taking written documents home to discuss with family members.

Client questions the healthcare provider about their prescribed plan of care. Rationale Clients who are proficient in health literacy exhibit the competencies of gathering their health records and asking appropriate questions of a healthcare provider.

A nursing team is reviewing its quality improvement plan. Which source of data will answer the question, "Are there fewer nosocomial infections this year"? Nurses' quarterly clinical performance evaluations. Client's outcomes from delivery of care processes. Post discharge client satisfaction surveys. Recommendations from the hospital's review committee.

Client's outcomes from delivery of care processes Rationale Quality improvement related to clinical goals is guided by the client's outcomes of the care processes they received during their hospitalization and/or client encounters.

Which situations describe palliative care? Comfort care offered a client with chronic pain from cancer radiation. The care is not related to the life expectancy of the affected person. Care directed towards the family members by providing grief support. Care begins when the client's life expectancy is less than six months. Care that improves the quality of life from the diagnosis, to include curative measures.

Comfort care offered a client with chronic pain from cancer radiation. The care is not related to the life expectancy of the affected person. Care that improves the quality of life from the diagnosis, to include curative measures. Rationale Palliative care is comfort care that is offered at any stage of a serious illness which is not based on the life expectancy of the client and the aim is to improve the quality of life, to include the delivery of curative measures.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.

Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice. Correct Answer: D

What is the most important action for the nurse who is implementing a standing order? Compare the order with the client's current status. Confirm the order with the healthcare provider. Transcribe the order into the record. Verify the order with another nurse.

Compare the order with the client's current status. Rationale The implementation of standing orders requires the nurse to use clinical judgment. Comparing the client's current status with the order is one way to apply clinical judgment.

client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.

Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the health care provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A) 31 gtt/min. B) 62 gtt/min. C) 93 gtt/min. D) 124 gtt/min

D) 124 gtt/min

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.

D) Ensure the accuracy of the blood type match All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition.

D) Hot remedies restore balance after surgery, which is considered a "cold" condition Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice.

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed

D) Immediately after the assessments are completed Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot

D) Move the chair parallel to the right side of the bed, and stand the client on the right foot (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.

D) Notify the healthcare provider of the family's request The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions

D) Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.

D) Re-oxygenate the client before attempting to suction again Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.

D) Upper arm circumference Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time.

D) is disoriented to place and time The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C).

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Correct Answer: D

Which foods should the nurse instruct a client diagnosed with end-stage renal disease to avoid? Select all that apply Bananas. Vegetables. Dark-colored colas. Red meats. Paste and rice.

Dark-colored colas. Red meats. Bananas. Rationale The client diagnosed with end-stage renal disease needs to avoid foods high in potassium such as bananas, high in sodium such as colas and high in protein such as red meats.

A client diagnosed with an incurable terminal disease states "If I adjust my work schedule, eat better and exercise more, I will be able to reverse the disease process and become disease-free". The nurse recognizes that this client is exhibiting which stage of grief as described by Kubler-Ross? Anger. Denial. Bargaining. Acceptance.

Denial. Rationale The client is exhibiting denial. The change in life style may slow down the disease, but it will not cure it.

Hospitals and other health care organizations receive payment for client services based on which factor? Bed census. Number of staff nurses. Diagnosis-related groups. Minimum data set.

Diagnosis-related groups. Rationale Hospitals and health care organizations receive payment based on diagnosis-related groups (DRGs). The DRGs are clustered medical diagnoses and the care and services related to treat the identified diagnoses.

The nurse is participating in the discharge planning meeting for a client who recently had a total colectomy and removal of the rectum due to cancer. Which referrals should the nurse include as part of the discharge planning? Select all that apply Dietician. Urologist. Cardiologist. Sex Therapist. Enterstomal Therapist.

Dietician. Sex Therapist. Enterstomal Therapist. Rationale A dietician will address the nutritional needs of the client due to removal of the colon. The sex therapist will address issues of possible sexual dysfunction due to removal of the rectum which may partially or completely disrupt the nerve supply to the genital organs. The enterstomal therapist will address issues in reference to an ileostomy bag since the colon and rectum were removed.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). Correct Answer: A

Excretion

ELIMINATION OF MEDICATION FROM THE BODY USUALLY DONE BY THE KIDNEYS BUT CAN BE DONE BY THE LIVER, LUNGS AND INTESTINES

An adult client has vomiting, diarrhea, dry mucous membranes, skin tenting, and delayed capillary refill. The client's vital signs are: HR 110, sitting BP 104/72 that drops to 84/62 when the client stands up. The client's laboratory results include: BUN 24 mg/dl and urine specific gravity 1.032. Which conditions should the nurse consider in planning care for this client? Extracellular fluid volume deficit.. Urinary retention. Postural hypotension. Cardiac output impairment. Impaired tissue perfusion.

Extracellular fluid volume deficit.. Postural hypotension. Impaired tissue perfusion. Rationale The nursing assessment indicates a fluid deficit. Skin tenting, postural hypotension, hemoconcentration noted in labs, and impaired tissue perfusion all indicate fluid volume deficit.

The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated. Correct Answer: B

secondary prevention

FOCUSES ON EARLY DETECTION OF DISEASES , LIMITING SEVERITY OF DISEASE.

AFFECTIVE LEARNING DOMAINS

FOCUSES ON FEELINGS, IDEAS , BELIEF AND VALUES

COGNITIVE LEARNING DOMAINS

FOCUSES ON THINKING, KNOWLEDGE, AND COMPREHENSION

Medicaid

Federal program that provides medical benefits for low-income persons.

What should the nurse do if an unusual and unexpected event involving a visitor or staff member occurs? Notify the hospital security office. Fill out an incident report immediately. Document the event in the client's record. Notify and consult the hospital's legal office.

Fill out an incident report immediately. Rationale When an unusual and unexpected event involving a client, visitor, or staff member occurs, an incident report should be filled out immediately to ensure accuracy of the details of the occurrence.

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.

Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary. Correct Answer: A

What is the best position for patients with cardiac and/or respiratory problems?

Fowler's position

The nursing process is the _____________ for all nursing activities.

Framework

anticipatory grief

GRIEVING BEFORE AN ACTUAL LOSS ( EX. FAMILY MEMBER WITH TERMINAL ILLNESS) INDIVIDUALS HAS THE OPPORTUNITIES TO START GRIEVING BEFORE THE ACTUAL DEATH

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Correct Answer: C

Who is responsible for ensuring the client fully understands the procedure?

Health care provider

A client has a swollen, bruised, sprained ankle and states that the current pain level has risen from a 3 to a 5 on a 10 point scale. Which analgesic medication would most likely be prescribed to relieve this pain? Morphine. Ibuprofen. Oxycodone. Acetaminophen.

Ibuprofen. Rationale Ibuprofen is indicated for mild to moderate pain relief. It is also a non-steroidal anti-inflammatory drug (NSAID) which inhibits the synthesis of prostaglandins which then inhibits the cellular response to inflammation.

The nurse is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump? If I am asleep, one of my visitors can push the button for me. The PCA is designed so I can try to maintain adequate pain relief. I don't need to be afraid of overdosing because the pump has preset doses to prevent that. The nurse will check the PCA pump syringe to check how often I am needing a dose.

If I am asleep, one of my visitors can push the button for me. Rationale The only person who should be pushing the dosing button of the PCA pump is the client. The pump has several safety features, including dosing limits.

You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?

Immediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present.

Third-Level Priority Problems

Important to the patient's health but can be addressed after more urgent health problems are addressed

What can nurses do to help facilitate the client's adherence to a plan of care? Include the client in the planning process. Set realistic goals that are acceptable to the client. Focus on establishing challenging overall long term goals. Offer teaching that supports the desired plan outcome. Ensure that the client independently decides the timeline.

Include the client in the planning process. Set realistic goals that are acceptable to the client. Offer teaching that supports the desired plan outcome. Rationale Adherence to a plan of care for a client is best achieved when the client is included in the planning process; realistic goals are set that the client finds acceptable; and the identication of necessary client teaching is done that supports the desired plan outcome.

Cellulitis

Infection of skin cells

A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? 1 Monitor the client's pain level for another hour. 2 Determine the integrity of the intravenous delivery system. 3 Reprogram the pump to deliver a bolus dose every eight minutes. 4 Arrange for the client to be evaluated by the health care provider.

Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.

ICN =

International Council for Nurses

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.

Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority. Correct Answer: C

In what ways does the Health Insurance Portability and Accountability Act (HIPAA) protect individuals? It gives clients the right to consent to disclosure of their records. It gives the clients the ability to choose private rooms only. It keeps individuals from losing health insurance when changing jobs. It ensures the message boards in rooms include the plan of care to ensure continuity. It requires nurses to maintain reasonable privacy when communicating with or about clients.

It gives clients the right to consent to disclosure of their records. It requires nurses to maintain reasonable privacy when communicating with or about clients. Rationale HIPAA is a federal regulation which helps people keep health insurance when changing jobs and protects the confidentiality and security of client's healthcare information.

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C

What steps should the nurse implement to ensure a client's confidentiality is maintained when working with electronic medical records (EMR)? Select all that apply Log off the computer when finished working on it. Do not give the log-on password to anyone. Give clients access to the computer to review their EMR. Protect computer screen from viewing by others.. Allow student nurses to chart under the nurse's password.

Log off the computer when finished working on it. Do not give the log-on password to anyone. Protect computer screen from viewing by others.. Rationale To protect a client's confidentiality, the nurse should log off the computer when finished working on it; never share their password to include giving, telling or allowing another nurse or student to work under their password; and never leave their computer screen open when not present or in a public area.

What do you check to see the dose to be given has not already been given by someone else caring for the patient?

MAR

Antagonist

MEDICATION THAT BLOCKS A RECEPTOR IN THE BODY.

CLASS 3 ( GREEN TAG)

MINOR INJURY

Larger vessel damage

Macroangiopathy

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification. Correct Answer: B

What actions should the nurse do when partnering with an interpreter to help teach a client about self-care instructions? Select all that apply Match the gender of the interpreter to that of the client. Use short sentences when giving instructions. Brief the interpreter about the client and the purpose of the session. Question family members to verify the accuracy of the interpretation. Ask the interpreter to periodically check if the client understands.

Match the gender of the interpreter to that of the client. Use short sentences when giving instructions. Brief the interpreter about the client and the purpose of the session. Ask the interpreter to periodically check if the client understands. Rationale The relationship between the client and the interpreter is built more quickly when the interpreter matches the client's age, gender and background. Prior to meeting with the client, the interpreter should be briefed about relevant information about the client and the purpose of the session. The nurse should ask the interpreter to speak as if the nurse were doing the speaking directly to the client in the first person. The nurse should use short sentences to allow time for the interpreter to translate and to seek out clarification from the client about the counseling instructions, questions and concerns.

Which federally-funded health care plan provides services to low income families? Medicaid. Medicare. Managed care organization. Preferred provider organization.

Medicaid Rationale Medicaid is a federally-funded program designated to provide health care services for low income families..

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)

Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.

The nurse is participating on a team writing the policy around sentinel events for the institution. Which topics should be included in the policy? Criminal investigation and penal code of liability are applied to all events. The occurrence signals that an investigation must begin within 2 months of the client event. Near misses are considered sentinel events and should be reported. Changes in nursing practice are implemented to prevent recurrence of the event. Sentinel events will lead to employee disciplinary action and dismissal.

Near misses are considered sentinel events and should be reported. Changes in nursing practice are implemented to prevent recurrence of the event. Rationale The occurrence of a sentinel event signals the need for immediate investigation and changes are implemented to prevent recurrence of the event. Near misses, even though they may not have affected the outcome, pose a significant chance of a serious outcome if it happens again and need to be reported as a sentinel event to the appropriate personnel for investigation. Sentinel events do not necessarily lead to action against the employee.

What must a licensed nurse do when moving from one state to another? Select all that apply Retake and pass the NCLEX to work in the new state. Notify the previous state board of the change of address. Inactivate the current license before obtaining a new one. Review the nurse practice act and practice guidelines in the new state. Seek permission from the new state board to work as a nurse.

Notify the previous state board of the change of address. Review the nurse practice act and practice guidelines in the new state. Seek permission from the new state board to work as a nurse. Rationale The licensed nurse needs to notify their previous state board whenever they changed their address, even if it is local, need to be aware of that each state's nurse practice act may vary and must be granted permission by the state board of nursing to work in that particular state.

What is the best description of evidence-based practice (EBP) in nursing? Nurses measure the effects of interventions on populations to determine individual client care. Nurses implement interventions which have already been determined to be safe and effective in clinical practice. Nurses generate answers to questions about interventions not already used in the care of clients. Nurses exchange traditional interventions and established clinical nursing practice for alternative, non-traditional approaches.

Nurses implement interventions which have already been determined to be safe and effective in clinical practice. Rationale The focus of evidence-based practice is the use of interventions that have already been determined to be safe and effective in clinical practice.

NURSING INTERVENTIONS THAT ARE CARRIED OUT DURING THE IMPLEMENTATION PHASE ARE (4)

PAIN MANAGEMENT NURSING PROCEDURES PREVENTING COMPLICATIONS TEACHING AND EDUCATING PTS

primary prevention

PREVENTS INITIAL OCCURRENCE OF DISEASE

Step 1 Drugs(non-opioid medications) can be given by

PRN

Modified Trendelenburg

PT LIES FLAT WITH LEGS ELEVATED ABOVE THE HEART

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B

Breakthrough pain

Pain that occurs between doses of pain medication

What sources can the nurse use for obtaining data for information about the client? (Select all that apply) Parents of a minor. Friends with consent. The client themselves. The person in the room. Medical power of attorney.

Parents of a minor. Friends with consent. The client themselves. Rationale The client themselves is the best source of information when alert and able. With minors and children their parents and with clients whom may be confused, comatose, absent or unable, the nurse may speak to friends only with consent or medical power of attorney.

The nurse is teaching a Health Promotion class to young adults. Which suggestion should the nurse make as the best way to detect and treat illness? Practice safe sex when being intimate. Participate in periodic health screenings. Engage in healthy eating and exercise. Build relationships with friends and family.

Participate in periodic health screenings Rationale Early detection of illness and disease can best be accomplished when young adults participate in periodic health screenings.

The nurse is advising a client to change high risk health behaviors. Which factors should the nurse consider when challenging a client's core beliefs? Personal choices are supported by core beliefs. Conflicting information may cause great distress. Core beliefs are only developed in childhood. Individuals seldom question their core beliefs. Core beliefs can easily be redirected with teaching.

Personal choices are supported by core beliefs. Conflicting information may cause great distress. Individuals seldom question their core beliefs. Rationale Core beliefs serve as an individual's foundation and basis of belief system. These beliefs are developed in childhood and continue to be refined throughout adulthood. Adults seldom question these beliefs and rarely replace them without a great deal of rethinking. Presenting information that challenges these beliefs often can cause a great deal of emotional and cognitive distress.

The nurse is auscultating the lung fields of a client exhibiting a low-pitched, grating and creaking sound during inspiration and expiration and notes that coughing does not clear the sound. Which term best describes this lung sound? Stridor. Coarse rhonchi. Wheezing. Pleural friction rub.

Pleural friction rub. Rationale Pleural friction rub is the correct choice. This sound is heard during inspiration and expiration and is not cleared by coughing. When the pleural surfaces are inflamed and rub together during respiration these sounds can be heard.

The nurse is assisting a client who is discouraged about losing weight. What skill can the nurse teach this client to encourage confidence, empowerment and motivation? Prioritization. SBAR method. Rationalization. Positive self-talk.

Positive self-talk. Rationale Positive self-talk is an internal conversation that provides motivation and encouragement; it may be used to build self-esteem and self-confidence and help with the sense of empowerment and the reduction of anxiety.

The nurse is interviewing a middle-aged client. Which factors indicate that the client is in a state of well-being? Positive social relationships. Financial wealth. Good health with regular exercise. Has multiple roles and responsibilities. Sense of control over life issues.

Positive social relationships. Good health with regular exercise. Sense of control over life issues. Rationale Factors that promote Well-being in Midlife are good health and exercise; sense of control and life investment; positive social relationships; a good marriage; and mastery of multiple roles.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D). Correct Answer: B

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery

Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Correct Answer: B

A spouse of a client appears to be in spiritual distress over the anticipated death of the client and is crying "Why is this happening to me?" What is the nurse's most therapeutic response? Remain with the spouse and listen empathetically. Explain to the spouse the steps of the grieving process. Gently ask the spouse why this is happening. Redirect the spouse's thoughts to think about of the good times.

Remain with the spouse and listen empathetically. Rationale A client experiencing spiritual distress does not require answers but requires someone who will actively listen and respond with empathy.

The charge nurse notices that many clients are complaining of not having pain relief from pain medications given during the previous shift. The charge nurse also notes incomplete documentation of client care and frequent inaccuracies of narcotic counts and inaccurate or vague shift reports whenever a particular staff nurse is on duty. What action should the charge nurse take in regards to these observations? Nothing, the staff nurse is providing competent care to assigned clients. Report the concerns about the staff nurse to the nursing supervisor. Request that a representative from Human Resources confront the staff nurse about the discrepancies. Question other nurses about the staff nurse and ask them what they think is going on with the nurse.

Report the concerns about the staff nurse to the nursing supervisor. Rationale If another nurse observes or questions whether or not other healthcare personnel may be impaired, the nurse's responsibility is to express concerns to the nursing supervisor and not to gossip with other health care personnel or directly confront the person in question.

Which behaviors are examples of secondary prevention in health care? Select all that apply Screening for diabetes mellitus. Checking for fecal occult blood. Wearing bicycle helmets. Vaccinating against rubella. Having a mammogram.

Screening for diabetes mellitus. Checking for fecal occult blood. Having a mammogram. Rationale Secondary prevention includes actions to help detect a disease or condition that is present so treatment can be started. Secondary prevention also includes actions to manage disease in its early stages. Screening for existing disease is an example of secondary prevention.

What is the wound closure called that occurs when the healing is prolonged because the skin or wound edges cannot be approximated? Primary intention. Secondary intention. Tertiary intention. Quadrant intention.

Secondary intention. Rationale Secondary intention is the correct choice. This occurs in cases such as pressure ulcers or a wound that is large or infected, all necrotic and infectious materials need to be removed first and the wound must fill in with granulated tissue.

Now Rx

Single order; STAT without emergency

Maximal lung expansion can be achieved by having the patient in what position?

Sitting

SBAR stands for:

Situation-Background-Assessment-Recommendation SBAR stands for Situation-Background-Assessment-Recommendation. It is an adaptation of a U.S. Navy communication technique and can be a very effective means to communicate urgent patient care issues

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium. Correct Answer: C

What is the leading cause of mortality?

Smoking

Advocacy =

Standing up for someone, other than oneself, when they are unable, or not prepared, to make a decision, or action, for themselves.

As the nurse inflates the balloon of a client's indwelling urinary catheter, the client reports pain and discomfort. What should the nurse do next? Stop and deflate the balloon of the catheter. Continue to inflate as the client takes slow deep breaths. Immediately remove the catheter and start over. Reposition the client and resume inflating the balloon.

Stop and deflate the balloon of the catheter. Rationale The nurse should deflate the balloon then advance the catheter another 2.5cm ( I inch) and re-attempt inflation.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed. Correct Answer: D

The nurse is updating unit policies and procedures. Which source provides the strongest evidence for practice changes? Randomized controlled trials and blinded studies. Practice guidelines and standards of care. Expert consensus and collaborative opinion. Systematic reviews and meta-analyses.

Systematic reviews and meta-analyses. Rationale Systematic reviews and meta-analyses summarize credible research and are considered one step above randomized controlled trials in most grading of evidence.

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C

A client is admitted to the emergency department with a wound that is draining green, purulent, and odorous exudate. Which approach will most likely be used to close this wound? Primary intention. Secondary intention. Tertiary intention. Quadrant intention.

Tertiary intention Rationale Tertiary intention is the correct choice. This is referred to as "delayed primary closure". In wounds that may be contaminated, infected or draining exudate, the wounds are intentionally left open to allow the wound to drain and once the infection has cleared up and granulation is present, then the wound is closed with sutures, staples and/or steri-strips.

The nurse should be familiar with which federal legislation that mandates the protection of client's personal health information? The Wagner National Health Act of 1939. The Patient Protection and Affordable Care Act of 2010. The Consolidated Omnibus Budget Reconciliation Act of 1985. The Health Insurance Portability and Accountability Act of 1996.

The Health Insurance Portability and Accountability Act of 1996. Rationale Federal legislation known as the Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandates the protection of client's personal health information.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.

The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.

The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C). Correct Answer: D

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct Answer: B

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.

The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct Answer: A

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C

A client has been taking a prescribed dose of 20 mg of oxycodone every 4 hours for the past three weeks for pain relief. The client reports that "The medicine is not working anymore." After notifying the healthcare provider, which action should the nurse anticipate? The oxycodone will be increased to 30mg every four hours. A referral should be make to a counselor for drug seeking behavior and addiction. The client should be informed that this is an expected outcome and will improve. The medication will be discontinued and hydromorphone will be started.

The medication will be discontinued and hydromorphone will be started. Rationale The client may have developed a drug tolerance to the oxycodone medication and it is better to change to another pain medication than to increase the dosage of the medication.

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct Answer: B

What are the three primary elements of the Health Belief Model (HBM) which predict how motivated a client is to change their self-care health behaviors? select all that apply The severity of the illness to the client. The socioeconomic status of the client. The client's highest level of education attained. The perception of susceptibility to the illness. The client's willingness to change life style choices.

The severity of the illness to the client. The perception of susceptibility to the illness. The client's willingness to change life style choices. Rationale There are three primary components of the HBM which are associated to a client's readiness and motivation to act: the first is the individual's perception of their susceptibility of the illness; second is their perception of the seriousness of the illness; and the third is the client's willingness to change or act on preventing the illness.

The nurse is irrigating a client's wound. Which factors could delay wound healing as a result of wound irrigation? Select all that apply The use of povidone-iodine solution. Hydrogen peroxide poured into wound. Normal saline used as an irrigation fluid. Direct force of irrigation solution on wound bed. Irrigation solutions cooler than room temperature.

The use of povidone-iodine solution. Hydrogen peroxide poured into wound. Direct force of irrigation solution on wound bed. Irrigation solutions cooler than room temperature. Rationale Povidone-iodine and hydrogen peroxide although cytotoxic to bacteria, are harmful to cells needed for wound healing. Cold irrigation solutions decrease the activity of leukocytes needed for wound healing. Too much force on wound bed will disrupts newly formed, fragile tissue in wound bed.

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.

Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D). Correct Answer: B

What are the reasons nurses should manage professional stress? To avoid nurse burnout. To safeguard client safety. To promote self-absorption. To decrease empathetic care. To reduce compassion fatigue.

To avoid nurse burnout. To safeguard client safety. To reduce compassion fatigue. Rationale By taking care of themselves and by managing professional stress, nurses can avoid nurse burnout and compassion fatigue. Both of these have been shown to cause problems with memory and concentration, irritability and a decreased ability to show empathy which impacts the quality and safety of care to the clients.

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D

The nurse is teaching a pre-op client in preparation for care following surgery. Which methods should the nurse teach about pulmonary toileting? To use measures to suppress coughing. To inhale deeply through pursed-lips. To use an incentive spirometer at least four times an hour. To breathe deeply through the nose and exhale through the mouth. To be sure to take short and shallow breaths in rapid succession.

To use an incentive spirometer at least four times an hour. To breathe deeply through the nose and exhale through the mouth. Rationale To breathe deeply through the nose and exhale through the mouth and use of the incentive spirometer are the correct choices. It is best to teach these techniques prior to surgery, so the client can practice prior. The benefit of performing these techniques will be to encourage lung expansion and help prevent the atelectasis and pneumonia.

The nurse is teaching a pre-op client in preparation for care following surgery. Which methods should the nurse teach about pulmonary toileting? To use measures to suppress coughing. To inhale deeply through pursed-lips. To use an incentive spirometer at least four times an hour. To breathe deeply through the nose and exhale through the mouth. To be sure to take short and shallow breaths in rapid succession.

To use an incentive spirometer at least four times an hour. To breathe deeply through the nose and exhale through the mouth. Rationale To breathe deeply through the nose and exhale through the mouth and use of the incentive spirometer are the correct choices. It is best to teach these techniques prior to surgery, so the client can practice prior. The benefit of performing these techniques will be to encourage lung expansion and help prevent the atelectasis and pneumonia.

Which pain relief intervention is based on the gate control theory of pain? Progressive deep relaxation exercises. Therapeutic music and sound therapy. The performance of massage therapy. Transcutaneous electrical nerve stimulation.

Transcutaneous electrical nerve stimulation. Rationale Transcutaneous electrical nerve stimulation (TENS) reduces pain impulses to the brain, a component of the gate control theory of pain.

What is the safest technique for lowering central venous pressure without decreasing BP?

Trendelenburg

STIUATIONAL LOSS

UNEXPECTED LOSS CAUSED BY EXTERNAL EVENT (EX. TORNADO , CAR ACCIDENT)

Sentinel Events

Unexpected occurrences involving death or serious complications.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat. Correct Answer: D

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Correct Answer: D

Which behaviors are examples of primary prevention? Skin testing for tuberculosis. Using bicycle helmets. Vaccinating against measles. Wearing seatbelts. Having a mammogram.

Using bicycle helmets. Vaccinating against measles. Wearing seatbelts. Rationale Primary prevention are health-promoting actions to prevent a disease or condition from happening and decreasing its impact. Wearing helmets and seatbelts is done to help prevents or minimizes injuries from collisions. Vaccinating against measles prevents the client from developing this disease.

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.

Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B

A four day old infant with no family members present is crying while lying in a bassinet in the nursery. What should the nurse do prior to implementing therapeutic touch? Assess the cultural beliefs of the infant's parents. Verify if the infant is receptive to being touched. Don't touch and allow the infant to self-soothe first. Dim the light, pick up the infant and rock teh infant slowly.

Verify if the infant is receptive to being touched. Rationale The nurse should be aware or verify that the child is receptive to being touched. This is true regardless of the age of the client. In this example, if this was a drug-exposed infant and going through withdrawals, touching them may overstimulate them and make the withdrawal symptoms worse. A caring touch can be used to soothe and let the client know they are not alone and another human being cares.

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?

Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference. Correct Answer: B

The nurse is auscultating the lung fields of a client who has been diagnosed with emphysema. The nurse notes high-pitched, whistling sounds throughout all lobes of the lung. Which term best describes this lung sound? Stridor. Crackles. Rhonchi. Wheezing.

Wheezing. Rationale Wheezing is the correct choice. The sounds are noted during inspiration and expiration and noted to be loudest during exhalation. The wheezing sound is caused by the constriction of the airways.

How should a nurse instruct a client on the proper use of the incentive spirometer? nhale holding the breath then blow continuously into the mouthpiece. Take small quick breaths and exhale through the mouthpiece. Wrap lips around the mouthpiece and inhale through the mouthpiece. Inhale deeply through the nose and exhale through the mouthpiece.

Wrap lips around the mouthpiece and inhale through the mouthpiece. Rationale Clients should be instructed to wrap lips around the mouthpiece and inhale through mouthpiece. The nurse should instruct the client to take a slow, deep breath and maintain a constant flow, like pulling through a straw. This technique helps maintain maximal inspiration and reduces risk for progressive collapse of a client's alveoli.

What is required prior to any invasive procedures?

Written informed consent

Do obese children generally become obese adults?

Yes

short

_____ acting insulin is not cloudy

long

______ acting insulin is cloudy

Transdermal Patch

an adhesive patch, placed on the skin to administer a specific dose of medication through the skin and into the bloodstream

Heaves or lifts

an unexpected , visible elevations of the chest wall , that indicates heart failure and are often along the left sternal border or at the PMI

actual loss

any loss of a valued person , item or status, such as loss of a job that can be recognized by others.

viscera

are all the internal organs inside the abdominal cavity

Step 2 and 3 Drugs(opioid medications) should be given -

around-the-clock

Epistaxis

bleeding from the nose

serosanguineous drainage

blood tinged, water

Jehovah's witness refuses -

blood transfusion

cyanosis

bluish discoloration of the skin

AU

both ears

OU

both eyes

Hematoma

bruise

dysuria

burning or painful urination

How is skin turgor assessed?

by pinching the skin and observing for tenting

Idiopathic Pain

chronic pain with unknown origin often associated with depression

serous drainage

clear, watery fluid ( usually the fluid in blisters)

Psychosocial Assessment consists of:

consists of substance abuse, caffeine use, history of mental illness, history of abuse or homelessness, home situation/significant others

baseline data consists of (4)

consists of vital signs, height, weight, and allergy status

CPAP

continuous positive airway pressure, consider when a pt that has apnea

Hospital and healthcare organizations receive payment based on -

diagnosis-related groups

Dysphagia

difficulty swallowing

dyspagia

difficulty swallowing

purulent

discharging pus

altitude sickness

disorder caused by being at high altitude, where oxygen levels are low.

Non-maleficense

do no harm

Nonmaleficence

do no harm

DNR means

do not resuscitate

Alginate

doesn't adhere to the wound

Anticholinergic effects include:

dry mouth, blurred vision, constipation, urinary retention

sputum samples should be collected when?

early in the morning, ideally through coughing (vs. suctioning)

lordosis

excess curvature of lumbar spine usually occurs in toddlers and pregnancy

Polydipsia

excessive thirst (as in cases of diabetes or kidney dysfunction)

Perfusion

exchange of 02 and c02 between the RBCs and the body tissues

aerosol mask/face tent is good for patients with -

facial trauma or burns, provides high humidification

Catholics

fast during Lent

Lanugo

fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn.

Skin turgor confirms the diagnosis of fluid ___ ?

fluid volume deficity

Jugular vein distention is a sign of

fluid volume overload

newborns sleep

for about 15 hrs a day

most important aspect of hand washing is -

friction

What is the goal of cultural assessment?

gather significant information from the patient that enables the nurse to implement culturally congruent and safe patient care

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B

what solution can be used to clean the inner cannula of a trach

half peroxide solution

Pendulous breasts

hangy breast

After performing percussion, vibration, postural drainage...

have a pt remain in the position for 10 to 15 minutes after

before you begin your physical examination

have pt use restroom and collect specimen if need be

Aloe

helps in burns and wound healing

Changes in behavior and mental status can be early signs of -

impaired gas exchange

intentional tort

imprisonment- when you appropriately restrain a pt with wrist or chemical restraints

Extrapyramidal Side is primarily associated with

improper dosing of or unusual reactions to antipsychotic medications

Ginkgo benefit:

improves memory

case manager (2)

improves the coordination of care reduces the fragmentation of care

Hyperresonance

in the presence of air unexpected findings::::: EX: pneumothorax emphysema

Urinary Retention

inability to void all urine collected in the bladder

Ginseng

increases physical endurance

Ginseng uses

increases physical endurance

Disparities =

inequality

Phlebitis

inflammation of vein

Garlic benefit:

inhibits platelet aggregation

Tertiary prevention

involves behaviors to treat existing disease and to prevent further complications

restorative care

involves intermediate follow-up care for restoring health and promoting self-care. -Examples include home health, rehab centers, and skilled nursing facilities

paralytic ileus

is a immobile bowel , no bowel sounds is present

kegel exercises

is for strengthen of the pelvic floor muscles

Head molding

is when the skull overlaps itself

Remote memory

is when you remember events from many years ago

after removing a foley cath from a pt

it could take up to 4 hrs before that pt voids

pruritus

itching or burning sensation in the skin

fidelity

keep your promise

Hydrogel dressing function

keeps moisture within the wound to reduce pain

elimination of medications from the body occurs where?

kidneys

Health literacy

knowledge of health information needed to make good choices about your health

Dyspnea

labored or difficult breathing

AS

left ear

OS

left eye

Where is the apex of the heart located?

left fifth intercostal space

glucose level wont show up in urine unless

level is above 220

Aphasia

loss of speech

If the BP cuff is too big, the reading can be

low

If the arm is positioned above the heart level during BP, the reading will be

low

Bell of the stethoscope is used to pick up

lower-pitched sounds

wash fake eye in

lukewarm water or hot water or with antibacterial soap if order by the doctor or manufacturer

Sim's position

lying on left side with right knee flexed

dorsal recumbent position

lying on the back with the knees flexed

Hydrocolloid dressing

made of gel forming agents like pectin or gelatin (most commonly used) that create a moist environment with the body to promote healing. It draws out the fluids and pus and then forms a soft gel.

Carbohydrates is the body's -

main source of energy

What is the purpose of suctioning?

maintain a patent airway by removing accumulated secretion.

Potassium (K)

maintains ICF, nerve function, regulates muscle and heart contractions

Sodium

maintains fluid balance in body, nerve and muscle function

Verbal directives

may be given to a health care provider with specific instructions in the presence of two witnesses

Uroflowmetry

measures rate and degree of bladder emptying

Medicare Part B

medical insurance

Federally funded health care programs

medicare medicaid

parenteral route

medication is given by injection or iv

Grapefruit Juice affects

metabolism of medications

What is the least restrictive restraint?

mittens

The ulnar pulse is located on:

opposite side of the wrist and feels less prominent

enteral route

oral, sublingual, buccal, and rectal

Dysuria

pain or discomfort during urination

dyspareunia

painful intercourse

dysmenorrhea

painful menstruation ( cramping)

Dyschezia

painful or difficult bowel movement

Analgesic

painkiller

passive smoking

people that is smoking around you

cathartic promotes -

peristalsis

what can be used to remove thick or crusty secretions from the inner cannula of a trach ?

pipe cleaner or small sterile brush

Where does pubic hair first grow?

pubic area then axillae

necessary loss

this type of loss can be replaced by something diff or better

Second-Level Priority Problems

those that are next in urgency requiring your prompt intervention to forestall further deterioration.

Alleviate

to relieve

Health perception

how the person describes and defines personal health

The nurse is teaching a female client who has had frequent urinary tract infections. Which statement by the client would indicate the need for additional teaching? "I need to urinate after having sexual intercourse." "I need to drink at least 2000ml of fluid a day." "I need to wipe my perineum from the back to front after using the toilet." "It is best to wash my hands before and after using the restroom."

"I need to wipe my perineum from the back to front after using the toilet." Rationale The proper direction to wipe is from the front of the perineum to the back after voiding and/or defecating to avoid contaminating the urethra.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

(C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem. Correct Answer: C

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct Answer: D

Nurses should not entrust others for: (4)

- patient education - any task requiring nursing judgement - nursing assessment - blood transfusion

Important things to remember about anti-embolic stocking: (7)

- promotes venous return - nurse removes once per shift - ensures no crease or wrinkle in stocking - prevent irritation - apply stocking in morning before client gets out of bed leg less edematous at that time - pt should avoid crossing legs - wear stocking while sitting in chair

Health Insurance Portability and Accountability Act (HIPAA) responsibilities: (3)

- protects confidentiality - security of client's healthcare information - helps people keep health insurance when changing jobs.

After a seizing episode, (4)

- take vital signs - reorient the PT - identify possible triggers - implement seizure precations

What are the 5 right of delegation?

- task - delegation - person - direction/communication - supervision/evaluation

What should be obtained after focusing on the pain assessment? (3)

- triggers - current drug usage - sympathetic responses

left midclavicular line, 5th intercostal space

-YOU CAN HEAR THE CLOSURE OF THE MITRAL VALVE -CLOSURE OF THE TRICUSPID VALVE

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? 1 "We have no record of that client on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 "The client has requested that no information be given out. You'll need to call the client directly." 4 "It is against the hospital's policy to provide you with any information regarding any of our clients."

1 The response "We have no record of that client on our unit. Thank you for calling." conforms to the request that no information be given regarding the client's condition or presence in the hospital. HIPAA laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others. Hospital policies do not prohibit the provision of information to others as long as the client consents. The response "It is against the hospital's policy to provide you with any information regarding any of our clients." also implies that the client is admitted to the facility.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube

1 Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? 1 Isotonic 2 Isomeric 3 Hypotonic 4 Hypertonic

1 Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure, because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving

1 The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1 Alcohol 2 Caffeine 3 Saw palmetto 4 St. John's wort

1 Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? 1 Give the infant to the client and instruct her regarding the infant's care. 2 Explain to the client that she can leave, but her infant must remain in the hospital. 3 Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. 4 Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge

1 When a client signs herself and her infant out of the hospital, she is legally responsible for her infant. The infant is the responsibility of the mother and can leave with the mother when she signs them out.

A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1 White blood cell (WBC) count of 15,000 mm3 2 Negative protein in the urine 3 Blood urea nitrogen (BUN) of 20 mg/dL 4 Prothrombin of 12.0 seconds

1 White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose.

1,2,4 Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs

1,2,5 With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation

1,3 Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members.

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. 1 Tremors 2 Lethargy 3 Palpitations 4 Visual disturbances 5 Decreased pulse rate

1,3 Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. 1 Ask the client what is the client's acceptable level of pain. 2 Eliminate all activities that precipitate the pain. 3 Administer the pain medications regularly around the clock. 4 Use a different pain scale each time to promote patient education. 5 Assess the client's pain every 15 minutes

1,3 The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals.

The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear

1,3,4 Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning of procedure. 4 Instill the solution directly onto cornea. 5 Press on the nasolacrimal duct after instilling the solution.

1,3,5 Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.

The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. Correct 1 Performing a bed bath for a client on bed rest 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered Correct 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy

1,4 Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

1,4,5 When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Incorrect 1 Dyspnea 2 Flushed face 3 Precordial pain 4 Increased pulse rate 5 Increased blood pressure

2,4 Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. 1 Orientation 2 Capillary refill 3 Pupillary response 4 Respiratory rate 5 Pulse and skin temperature 6 Movement and sensation

2,5,6, A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%

3 Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.

Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings. Correct Answer: C

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1 It stimulates plasma cells directly. 2 A high titer of antibodies is generated. 3 It provides immediate active immunity. 4

2 A long-lasting passive immunity is produced. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.

2 Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? 1 The nurse also should have instituted a plan to increase activity. 2 The nurse provided supportive nursing care for the well-being of the client. 3 Debridement of the pressure ulcer should have been done before the dressing was applied. 4 Treatment should not have been instituted until the health care provider's prescriptions were received.

2 According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions.

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2 The child had a right to remain in the room with the other children. 3 The child had to be removed because the other children needed to be considered. 4 Segregation of the child for more than half an hour was too long a period of time

2 Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated

In what position should the nurse place a client recovering from general anesthesia? 1 Supine Correct2 Side-lying 3 High Fowler 4 Trendelenburg

2 Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing.

Keep child in the back seat until -

2 years old

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat

2,4 Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. 1 After reporting severe pain 2 On admission to the hospital 3 Upon entering the operating room 4 Before transfer to a rehabilitation facility 5 At time of scheduling for the surgical procedure

2, 4 Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.

Which rights of medication administration are ensured with "bar-coding technology" which requires the nurse to scan the medication, client's identification bracelet and nurse's identification badge prior to administering medication? Right reason. Right dose. Right time. Right route. Right client.

Right dose. Right time. Right client. Rationale The bar-coded technology of medication administration helps ensure the right medication, right dose, right time, and right client when scanned and inputted into the computer medical record. The nurse still needs to be aware of how to deliver the right route of administration of the medication.

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance

4 Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty 4 False imprisonment

4 False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? 1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. 4 The antigen is neutralized by the antibodies that it supplies

4 Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? 1 Incisional pain 2 Absent bowel sounds 3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing .

3 A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, since this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Correct Answer: D

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Incorrect1 Occipital headache 2 Periorbital crepitus 3 Expectoration of blood 4 Changes in vocalization

3 After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

Fluid requirements

2000-3000 a day from foods and fluids

incident report should be completed within -

24 hrs

Fiber recommendations

25-30 g/day

Visitors should sit __ ft away from pt with cough

3

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue

3 A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.

The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1 Protein 2 Glucose 3 Ketones 4 Uric Acid

3 As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine. Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen

3 Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate droplet precautions. 3 Move the client to a private room. 4 Use a high efficiency particulate air (HEPA) respirator during care.

3 Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet, but are not suspended for long periods.

A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? 1 An acquired atopic sensitization occurred. 2 There was passive immunity to the penicillin allergen. 3 Antibodies to penicillin developed after a previous exposure. 4 Potent antibodies were produced when the infusion was instituted

3 Hypersensitivity results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not passive, immune response. Antibodies developed when there was a previous, not current, exposure to penicillin.

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit

3 If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.

A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? 1 Curling ulcer 2 Renal shutdown 3 Metabolic acidosis 4 Hemolysis of red blood cells

3 Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic acidosis. Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse effects of the drugs.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's 3 End-stage renal 4 Gastroesophageal reflux .

3 One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause

3 Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? Rehabilitation needs are met best by the client's family and community resources. Rehabilitation is a specialty area with unique methods for meeting clients' needs. Immediate or potential rehabilitation needs are exhibited by clients with health problems. Clients who are returning to their usual activities following hospitalization do not require rehabilitation.

3 Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

3 Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.

A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? 1 Nursing's Social Policy Statement 2 State law regarding protection of minors 3 ANA Standards of Clinical Nursing Practice 4 References regarding a child's right to consent

3 The ANA Standards of Clinical Nursing Practice guidelines govern safe nursing practice; nurses are legally responsible to perform according to these guidelines. Nursing's Social Policy Statement explains what the public can expect from nurses, but it is not used to govern nursing practice. There are no data that indicate state law regarding protection of minors and references regarding a child's right to consent are necessary.

A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1 Abrasion 2 Fracture 3 Crush injury 4 Incisional laceration

3 The bite of a large dog can exert between 150 and 400 psi of pressure, causing a crush injury. A crush injury may or may not include a fracture. Abrasions and incisional lacerations are not caused by this form of trauma.

A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1 A defibrillator 2 An IV infusion pump 3 A tracheostomy tray 4 An electrocardiogram (ECG) monitor

3 The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism

3 When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties

3 With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Incorrect 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli .

3,4 Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias

3,4,5 Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness

3,5 Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia, bradycardia is.

A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.

4

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.

4

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force

4

A health care provider prescribes 10 mL of a 10% solution of calcium gluconate for a client with a severely depressed serum calcium level. The client also is receiving digoxin (Lanoxin) 0.25 mg daily and an intravenous (IV) solution of D5W. The nurse's next action is based on the fact that calcium gluconate: 1 Can be added to any IV solution Incorrect2 Must be administered via an intravenous piggyback (IVPB) 3 Is non-irritating to surrounding tissues Correct4 Potentiates the action of the digoxin preparation

4 Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate cannot be added to a solution containing carbonate or phosphate because a dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the client is receiving. If calcium infiltrates, sloughing of tissue will result.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

4 A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought

4 The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal basis, and the nurse may be held liable.

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

4 The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site

4 This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? 1 Vitamin A (Aquasol A) 2 Cyanocobalamin (Cobex) 3 Phytonadione (Mephyton) 4 Ascorbic acid (Ascorbicap)

4 Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress

4 When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.

Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 t

4,5 Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred. Correct Answer: D

Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy

A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.

A) Determine the etiology of the problem Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders.

A) Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems (B), so it is not a reason to seek health care (C). A genogram is not a diagnostic tool to detect disorders (D), such as those based on pathological findings or DNA.

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry.

A) Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope

The nurse is reviewing the change of shift report. Which client should the nurse assess first? A 46-year old client admitted yesterday undergoing bowel prep for abdominal surgery. A 76-year old client transferred from the emergency department who requires femur pinning due to a recent fall. A 55-year old client who had knee replacement and is scheduled to be discharged that day. A 22-year old client transferred from the emergency department scheduled for shoulder surgery due to a rotator cuff tear.

A 76-year old client transferred from the emergency department who requires femur pinning due to a recent fall. Rationale Because of the client's advanced age and history of falling, the 76-year old client should be assessed first.

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records

A) Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF

A) Commend the client for selecting a high biologic value protein Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary

A mother asks for advice on how to talk to her children about death and dying after she learned that her husband has approximately six months to live. How should the nurse respond to the mother? Ask the mother about her beliefs about death and dying. Assess how the mother feels about the situation. Inform the mother that she will need to discuss this with the chaplain. Inquire about her children's previous experiences with death and dying. Advise the mother it would be best to avoid this topic with the children.

Ask the mother about her beliefs about death and dying. Assess how the mother feels about the situation. Inquire about her children's previous experiences with death and dying. Rationale Further assessment is needed. Death and dying are very personal experiences. It is important to listen to the mother's views, beliefs, and perceptions of the situation and how she feels about it. It is also important to help guide the mother on how to approach her children about this topic by having the mother reflect on her children's past experiences and how they have responded in the past about this topic.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure

B) A decreased flow rate could result in the formation of a thrombosis Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation

B) During the inhalation The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C).

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.

B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) prone. B) Fowler's. C) Sims'. D) supine

B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses

B) Initiate an alternate site for the IV infusion of the medication A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure

B) Instruct the client that the stoma will become smaller when the initial swelling diminishes Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D).

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. B) often follows relocation to new surroundings. C) is a result of irreversible brain pathology. D) can be prevented with adequate sleep

B) often follows relocation to new surroundings Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.

C) Examining a chest x-ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider.

C) Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation

Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first.

C) Keep gloved hands above the elbows Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal.

C) Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level.

C) Reposition in a Sim's position with the client's weight on the anterior ilium The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie.

C) Skim milk, turkey salad, roll, and vanilla ice cream Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium

Palliative Care

Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family.

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D). Correct Answer: C

When applying restraints, which action is most important for the nurse to take to prevent contractures? Pad skin and any bony prominences that will be covered by the restraint. Correct anatomical positioning where restraint is applied and is restricting movement. Assess the neurovascular status of the area which is restrained or has movement restrictied. Inspect the area where restraint is to be placed, ensuring there are no tubing or devices present.

Correct anatomical positioning where restraint is applied and is restricting movement. Rationale Correct anatomical positioning where the restraint is to be applied and restricting movement will help prevent contractures. Other options are important but do not directly address prevention of contractures.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes. Correct Answer: C

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A) Explain that anyone who speaks her language can answer her questions. B) Provide a translator only in an emergency situation. C) Ask a family member or friend of the client to translate. D) Request and document the name of the certified translator.

D) Request and document the name of the certified translator A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred.

An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.

D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C).

The nurse requests to switch a client assignment with another nurse because the assigned procedure would conflict with the nurse's personal beliefs and values. What is this nurse demonstrating? Select all that apply Ethical decision making. Moral courage. Professional autonomy. Compliance with minimal standards. Prejudicial client treatment.

Ethical decision making. Moral courage. Professional autonomy Rationale The nurse demonstrated professional autonomy by having self-determination and making a legally acceptable decision based on personal values and beliefs. The nurse also demonstrated moral courage by not assisting in a procedure which conflicted with personal beliefs. Ethics was also demonstrated by using professional judgment in not abandoning the client and switching client assignments with another nurse.

The nurse requests to switch a client assignment with another nurse because the assigned procedure would conflict with the nurse's personal beliefs and values. What is this nurse demonstrating? Ethical decision making. Moral courage. Professional autonomy. Compliance with minimal standards. Prejudicial client treatment.

Ethical decision making. Moral courage. Professional autonomy. Rationale The nurse demonstrated professional autonomy by having self-determination and making a legally acceptable decision based on personal values and beliefs. The nurse also demonstrated moral courage by not assisting in a procedure which conflicted with personal beliefs. Ethics was also demonstrated by using professional judgment in not abandoning the client and switching client assignments with another nurse.

A client who was administered a medication ten minutes ago is now reporting a rash, itching, and a headache. What is the first action the nurse should take? Evaluate the client's vital signs. Immediately administer epinephrine. Notify the healthcare provider "STAT". Activate the emergency response system.

Evaluate the client's vital signs. Rationale Based on the presenting signs and symptoms the client appears to be experiencing a hypersensitivity reaction to the medication received. The nurse needs to evaluate the client's vital signs to ensure the client is not becoming hypotensive and tachycardia which would be signs of impending anaphylaxis reaction to the medication.

Place each step of the nursing process in the order that it should be used. Correct 1. Obtain client's nursing history. Correct 2. State client's nursing needs. Correct 3. Identify goals for care. Correct 4. Develop a plan of care. Correct 5. Implement nursing interventions.

First the nurse should gather data. Based on the data, the client's needs are assessed. After the needs have been determined, the goals for care are established. The next step is planning care based on the knowledge gained from the previous steps. Implementation follows the development of the plan of care.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Correct Answer: B

The nurse is assessing a client who has reported 7 episodes of diarrhea in the past 24 hours. What questions would determine a possible causative factor of the diarrhea? Select all that apply Have you been experiencing any stress or anxiety lately? Does the diarrhea have a strong, unpleasant odor to it? What type of food have you eaten within the last 36 hours? What medications and supplements are you currently taking? When did you last urinate and what was the color and amount of the urine?

Have you been experiencing any stress or anxiety lately? Does the diarrhea have a strong, unpleasant odor to it? What type of food have you eaten within the last 36 hours? What medications and supplements are you currently taking? Rationale Asking about recent stress, food intake, medications, and characteristics of the diarrhea are all useful questions. Any of the correct questions could lead to a causative factor.

In what ways has nursing evolved?

Nursing is no longer considered a "less than" job and instead is recognized as a highly respected profession. Practice has widened to cover a wide variety of health care settings. Nurses have a specific body of knowledge. Nurses have an ethical conduct. Nurses value research and continuously publish scholarly research. Nurses don't just "care for sick people;" nurse promote health as well. Nursing is continuously growing as a highly professional discipline.

The nurse calculates a client's body mass index (BMI). The client's height is 6 feet and 6 inches (198cm) and the BMI is 30. How should the nurse categorize this BMI? Obesity. Overweight. Underweight. Normal weight.

Obesity. Rationale A BMI of 30-39 is considered obesity according to the U.S. National Institutes of Health.

What should the nurse do to demonstrate proper body mechanics when assisting a client to a standing position from a sitting position? (Select all that apply.) Rock their own body weight as they pull the client up towards them. Keep their own knees locked as they lift the client in a smooth motion. Stand in front of the client, move their own feet apart and bend at the knees. While standing behind the client, secure their own arms around the client's chest and lift upward. Assess the client and determine whether or not another care provider is needed to assist.

Rock their own body weight as they pull the client up towards them. Stand in front of the client, move their own feet apart and bend at the knees. Assess the client and determine whether or not another care provider is needed to assist. Rationale Pulling is easier than lifting and the momentum by rocking the nurse's body uses that body weight to enhance the force of arm muscles. Moving feet apart widens the base of support and bending knees lowers the center of gravity. These actions are elements of safe body mechanics. When possible, use teams to lift clients ast is decreases the incidences of lower back injuries in healthcare workers and is safer for the client.

The nurse is assessing a client for risk of falls. Which client behavior would be the most informative to the nurse? The client transfers unassisted from the bed to a chair next to the bed. The client changes positions in bed from a prone position to sitting upright at 45 degrees. The client is able to rise from a chair without using arms for support and walk 10 feet and turn around. The client with gait belt attached ambulates up and down the hallway with the physical therapist next to them.

The client is able to rise from a chair without using arms for support and walk 10 feet and turn around. Rationale A client's ability to get up from a sitting position without using their arms for support and walk 10 feet and turn around would give the nurse an assessment of the client's balance, coordination and gait as they walked.

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. Correct Answer: B

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.

The client should be positioned in a semi-sitting or Fowler's (B) position during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often referred to as a PEG tube, is inserted directly into the stomach through an incision in the abdomen and is used when long-term tube feedings are needed. In (A and/or C) positions, the client would be lying on his abdomen and on the tubing. In (D), the client would be lying flat on his back which would increase the chance of aspiration. Correct Answer: B

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.

The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high. Correct Answer: A

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding. Correct Answer: A

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy. Correct Answer: B

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). Correct Answer: C

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of sensory and motor functions. Correct Answer: C

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D). Correct Answer: C

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D). Correct Answer: B

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A). Correct Answer: A

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented. Correct Answer: D

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). Correct Answer: A

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.

The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. Correct Answer: A

Which has been shown to be the most effective intervention a nurse can perform to prevent most hospital-acquired infections? Maintaining sterile technique during procedures. Washing hands before and after each client contact. Abiding by the hospital's established isolation room protocols. Assuring nures assigned to surgical clients do not care for infectious clients.

Washing hands before and after each client contact. Rationale Hand hygiene is the most effective method to prevent hospital-acquired infections.

Which questions would be relevant for a nurse to ask a client who suffers with chronic pain? What makes it better or worse? Can you show me where it hurts? How would you describe the pain? How has this pain affected your life? Do you think your pain is psychological?

What makes it better or worse? Can you show me where it hurts? How would you describe the pain? How has this pain affected your life? Rationale The nurse should ask questions about the symptoms and management of pain and how the pain has affected the client's life.

The nurse signs the consent form to:

witness the client voluntarily sign the consent

Professional Autonomy

working independently, making decisions without much supervision

What is required for every medication that needs to be administered?

written prescription

Advance Directives

written statements of a person's wishes regarding medical care

Intravenous pyelogram

x-ray exam that uses an injection of contrast material to evaluate your kidneys, ureters and bladder and help diagnose blood in the urine or pain in your side or lower back.

What is the BEST indicator that the NG tube is properly placed?

chest x-ray

Glaucoma

chronic eye disease that can be controlled through lifelong management but can not be cured.

Maintaining a closed urinary drainage system is important to prevent infections, so the most immediate priority is to -

close the clamp to reduce risk for ascending microorganisms.

atelectasis

collapsed lung

ishihara

color vision test

wet to dry dressing

common for debriding and is usually painful

Normal curvature of spine

concave of the spine

Orthostatic Hypotension

condition in which your blood pressure falls significantly when you stand up quickly

Chronic venous insufficiency

condition that occurs when the venous walls and/or valves in the leg veins are not working effectively, making it difficult for blood to return to health from the lungs.

If the BP cuff is too tight, the reading can be

high

Medicare Part A

hospital insurance

A diet low in protein could have contributed to generalized

edema

First-Level Priority Problems

emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing

Phagocytosis

engulfing foreign substances and destroyed by lysosomes.

state board licensing

ensures that health care providers comply with regulations

disenfranchised grief

entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide and abortion

evaluation

goals was met,partially met or not met

Air conduction is normally ___ than bone conduction

greater

Alginate dressing

help establish homeostasis while providing a moist environment for healing and good absorption of exudate

aloe

helps in burns/wound healing

speech-language pathologist

helps patients with speech and they do swallowing assessments

incentive spirometry

helps to increase inspiratory volume main alveolar ventilation

infants have limited medication -

metabolizing capacity

Aseptic technique

method used to make the environment, the worker, and the patient as germ-free as possible

Venturi mask

most precise oxygen delivery

Myasthenia Gravis

muscle weakness

Nutrition Assessment includes:

ncludes current diet, any chewing or swallowing problems , recent weight gain or loss, use of supplements, and dentures

myopia

nearsightedness

Magnesium

nerve and muscle function, bone formation

Maturation or remodeling phase

occurs day 21 to 1-2 years post injury & involves the strengthening of the collagen

baden scale is for

predicting pressure sore risks

vitamins and minerals C and Zinc

promote wound healing

Valerian benefit:

promotes sleep, reduces anxiety

compression devices

promotes venous return in the deep veins of the legs and thus helps prevent thrombus formation

Primary Survey

rapid assessment of a life threatening injury, should take no more than 60 seconds...should be complete systematically so you don't miss anything. Use ABCDE

Fluid bolus

rapidly replaces fluid loss of dehydration shock , hemorrhage, burns, or trauma use a 18 gauge needle for adults

purosanguineous exudate

red tinged pus (NEWLY INFECTED WOUND)

restraints

remove them one at a time

What should the nurse do when the NG tube causes client to be nauseated or does not have drainage?

reposition the client to their side

RACE means

rescue, alarm, confine, extinguish

Where is the base of the heart located?

right second intercostal space

rhinorrhea

runny nose

Flow charts shows -

shows trends in vital signs, blood glucose levels, pain level, and other frequent assessments

frostnip (frost bite)

skin and the tissue just below the skin freeze - does not lead to tissue injury and can be treated by warming

Peptic Ulcer

sore that develops on the lining of the esophagus, stomach, or small intestine

Echinacea benefit:

stimulates immune system; used as a cold and flu preventative

Asthma report that symptoms worsen with -

stress

Etiology

study of causation, or origination of disease

Narcolepsy

sudden attack of sleep or excessive sleepiness during waking hours often happen at inappropriate times and increases risk of injury

Corticosteroids

suppress the immune system and can delay the healing process of a wound

Ostomy

surgery to create a stoma from an area inside the body to the outside to treat certain disease of the digestive or urinary systems

veracity is to -

tell the truth

Evaluation in the nursing process examines:

the effectiveness of nursing interventions in achieving client outcomes

Menarche

the first menstrual period

unintentional tort

the nurse didn't mean to hurt the pt but they did because of negligence

The ICN also says that nursing care includes:

the promotion of health, prevention of illness, & the care of ill, disabled, & dying.

The ultimate authority of nursing practice is . . .

the state board of nursing

role conflict

the tension caused by competing demands between two or more roles pertaining to different status

Moral Courage

the will to stand up for what is right, regardless of personal cost

2 medication can compete for the same site resulting in?

toxicity

subligual

under the tongue

increased sodium leads to decreased -

urination

Bed cradle

used to keep the top bedclothes off the client

Damp to damp 4-inch by 4-inch dressings

used to mechanically debride a wound until granulation tissue starts to form in the wound bed

Soaps suds enema

used to treat constipation

Antiemetic medications

used to treat nausea and vomiting

cystourethroscopy

visual examination of the urethra and bladder

After receiving nose medications wait -

wait 5 min before you blow your nose

Wet to Dry Dressing

wet gauze dressing put on the wound and allowed to dry.

Dehiscence

when a surgical incision reopens either internally or externally

role ambiguity

when role expectations are not clearly understood

Nurse Manager

who is in-charge of improving coordination of care and reducing the fragmentation of care

palpate axillary and clavicular lymph nodes

with the client sitting with her arms at her sides. Expect them to be nonpalpable with no tenderness