Concepts Exam 3 PrepU
The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.
Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.
Why are health promotion and illness prevention a key responsibility of nurses?
Chronic illnesses are the leading health problem in the world.
Which of the following is considered to be the most potent neuromodulators?
Endorphins Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.
The nurse is caring for a client with a 35% Venturi mask. Which administration considerations should the nurse use? Select all that apply.
Ensure that air intake valves are not blocked. Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. Use gauze pads under elastic strap to relieve irritation to scalp or ears.
The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?
Examine the effectiveness of the current pain regimen When a client has a painful diagnosis and is nearing the end of life, pain management is the priority.
The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period?
Food and liquids will be held in the immediate postoperative period.
A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response?
Inform the anesthesiologist or surgeon of this fact. The surgeon or anesthesiologist must be informed if a client has not adhered to preoperative fasting instructions, since this constitutes a risk for aspiration
The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate?
It decreases dry mucous membranes by delivering small water droplets.
Which nursing activity reflects secondary prevention?
Making a referral for a mammogram Discussions about wearing helmets, using seat belts, and drugs and alcohol are all examples of primary prevention, which focuses on promoting health and preventing disease.
Bowel movements absend after surgery. What is indicated?
Monitor the client closely and promote fluid intake. Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery.
The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?
Notify the physician of the oversight. Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as opioids or barbiturates, can alter cognitive abilities and invalidate informed consent.
The health care provider prescribes lidocaine 2.5% and prilocaine 2.5% cream (EMLA) to decrease the pain associated with the procedure. When should the nurse administer the cream?
One hour prior to the procedure
A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client?
Place the client in semi-Fowler's position.
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
Pulse Oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?
Respiratory
The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person?
Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact.
Which model is most useful in examining the cause of disease in an individual, based upon external factors?
The Agent-Host-Environment Model
The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed?
The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx.
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as
"Acute pain tends to increase during the day and is called a routine pain response"
The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider?
"I've been taking ibuprofen for my hip pain twice a day." since this medication can cause the complication of postoperative bleeding.
When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?
The client and the nurse are equal participants.
Two hours after receiving a pain medication, the client reports still suffering from pain. Which response is most appropriate?
"Tell me more about your pain." Pain intensity indicates the magnitude or amount of pain perceived. Terms used to describe pain intensity include none, mild, slight, moderate, severe, and excruciating. Pain intensity also may be described on a numeric scale. The most appropriate assessment is one which allows for all information and is broad.
The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client?
"Use a pillow to splint the incision." The client needs to use a pillow to splint the incision during movement to reduce pain. The client needs to change position every 2 hours or less;
A nurse is teaching an older adult client to use an incentive spirometer following hip replacement surgery when the client asks why using this machine is necessary. How will the nurse respond?
The exercise helps prevent pneumonia.
The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. What is a likely reason for the client's decreasing oxygen saturation?
The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. A sudden drop in oxygen saturation without clinical signs or symptoms may be caused by disruption of oxygen flow
A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives?
The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.
ablative surgery
To remove a diseased body part. e.g., Appendectomy.
Which factor is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery?
Type of Surgery
Which scenario is an example of a characteristic of Stage 2 of illness?
A person tells his family that he is sick and allows family members to take care of him.
Understanding basic information and services needed to make appropriate health decisions is an important part of a patient's:
A.Health literacy.
A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first?
A.How to use an inhaler during an asthma attack
Learning
the process by which a person acquires or increases knowledge or changes behavior in a measurable way as a result of the experience
The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
adequate tissue perfusion.
The nurse knows the term perioperative phase refers to care given to the client:
before, during, and after the operative phase.
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
congestive heart failure
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?
procedural pause (time-out)
A nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use?
sedation
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?
"Breathing through your nose first will warm, filter, and humidify the air you are breathing."
The nurse is interacting with a new client who reported to the clinical facility for a health problem. Place the following statements by the nurse in the order of the nurse-client relationship. Use all options.
"Hello. I am the nurse assigned to you. My name is...." "What health problem are you seeking help for?" "This medication has been prescribed by the health care provider to treat your problem." "The health care provider has recommended you to return in 1 week." There are three phases in the nurse-client relationship. The first phase is the introductory phase. In the introductory phase, the nurse gets acquainted with the client by introducing oneself and identifying the role of the nurse. The nurse assists the client in identifying the health problems for which the client is seeking help. The next phase in the nurse-client relationship is the working phase. The working phase is the period when tasks are performed, such as medication administration. The terminating phase is when the relationship comes to an end. An example is when the client is being discharged.
A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?
A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment Cultural issues, a low income, poor family support, and lack of transportation are potential barriers to obtaining needed care. If a client must choose between work and keeping an appointment, scheduling is an important factor. The characteristics of a client who will keep appointments with specialists include those clients who have been well educated about the importance of the referral, understand the benefit to seeing a specialist, and will not have to struggle to keep the appointment. A client who agrees, who has input in scheduling, and shows curiosity or hope about the benefit of the referral is more likely to keep the appointment.
The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?
A client who has a sprained ankle Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. This is the type of pain that results from introduction of an intravenous access line. A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:
Apnea This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
Assess for medication prescription for breakthrough pain.
The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply.
Available resources Learning style preferences Literacy level
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
Clubbing Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.
When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?
Cognitive cognitive domain- where information is processed by listening or reading facts and descriptions. The affective domain is a style of processing that appeals to a person's feelings, beliefs, or values The psychomotor domain is a style of processing that focuses on learning by doing. The interpersonal domain is a style of processing that focuses on learning through social relationships
The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?
Crackles Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Rales are small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). Vesicular breath sounds are heard across the lung surface.
The nurse is preparing a sterile field for a procedure. While the nurse is opening an instrument, the outer wrapper of the sterilized instrument touches the extreme edge of the field. What should the nurse do next?
Discard sterile field and prepare a new one
The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?
Explore the client's feelings and inform the surgeon.
A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply.
Have someone available for transportation home after recovery from anesthesia. Notify the surgeon's office if a cold or infection develops before surgery. List allergies and be sure the operating staff is aware of these. NOT: Continue with all medications routinely taken. The nurse should list medications routinely taken and ask the physician which should be taken or omitted the morning of surgery.
Which is the most accurate definition of health?
Health is a state of complete physical, mental, and social well-being.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?
High Fowler's Position - 90 degrees
The recognition of health as an ongoing process toward a person's highest potential of functioning is defined as:
High level wellness
The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?
If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. Acute respiratory distress syndrome is caused by sepsis, inhaling harmful substances, injury, and severe pneumonia that has infiltrated all five lobes and is not specific to postoperative-related pneumonia.
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?
Implement leg exercises and turn the client in bed every 2 hours. Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids.
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?
Implement leg exercises and turn the client in bed every 2 hours. - do not place a pillow under the legs!!
Which drug has the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to?
Physical dimension The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices.
A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client?
Place the client in a flat position with legs elevated 45 degrees.
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?
Pleural effusion
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?
Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
A nurse is immunizing children against measles. This is an example of what level of preventive care?
Primary Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Immunizations are an example of primary health promotion. Secondary health promotion and illness prevention focus on screening for early detection of disease, with prompt diagnosis and treatment of any found. Tertiary health promotion and illness prevention begin after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate clients to a maximum level of functioning. (low sodium diet, rehab, taking care of health after the fact)
A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes
Psychomotor learning
Which are characteristics of chronic conditions?
Require lifelong management Have a prolonged course Are rarely curable
The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency?
Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema.
Clients bladder before surgery
Should be emptied!
Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone?
Sociocultural needs Increased social interaction, as would be provided by visiting a senior citizen community center, would primarily address a client's sociocultural needs. Emotional needs address how the mind affects body functions and responds to body conditions. Long-term stress affects body systems, and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change the body's responses to illness. The intellectual dimension encompasses cognitive abilities, educational background, and past experiences. Spiritual beliefs and values are assessed when addressing spiritual needs.
The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing?
Teach the client how to splint the abdomen while coughing. Splinting the abdomen decreases discomfort while coughing. Use a pillow
When first diagnosed with cancer, a client was depressed and complained of feeling sick. Now the client has adapted to the diagnosis, recently returned to work, and, since undergoing chemotherapy, reports feeling better than ever. The nurse recognizes that which model of health promotion is most effective in explaining this client's situation?
The Health-Illness Continuum Model
When a nurse is planning for learning, who must decide who should be included in the learning sessions?
The nurse and the client The nurse cannot assume that family members are wanted by the client to be included. The client must always be included in the learning session.
A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.
The nurse fails to accept that clients have the right to change their minds. The nurse uses medical jargon frequently when discussing the teaching plan. The nurse ignores the restrictions of the client's environment. The nurse SHOULD: The nurse negotiates goals with the client. The nurse evaluates what the client has learned. The nurse reviews educational media when planning learner objectives.
A student nurse is preparing a presentation on pain management. What information regarding nonpharmacologic interventions should he include? Select all that apply.
Use cold packs for muscle spasms and surgical site pain. Ice packs should not be left on longer than 20 minutes. Massage can stimulate circulation. Distraction is useful for short pain periods. Not: Dry heat penetrates deeper than moist heat.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?
Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.
The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?
What people believe to be true about their health The Health-Illness Continuum Model focuses on health as a constantly changing state, whereas The Agent-Host-Environment Model explains how certain factors place a person at risk for an infectious disease.
What assessments would a nurse make when auscultating the lungs?
air flow through the respiratory passages
The nurse is caring for a client who has been admitted to an acute care unit after surgery. When reviewing the client chart, what information will the nurse expect to find in the intraoperative record?
completion of skin preparation The intraoperative phase begins when the client is transferred to the operating room bed and ends upon transfer to the post-surgical recovery area. One of the interventions performed in this phase is skin preparation. The preoperative phase provides client teaching regarding the surgical experience, including a visit by the anesthesiologist. - clients should empty the bladder before surgery, typically NPO The postoperative phase begins immediately after the surgical procedure is completed when assessments and therapies are performed, such as taking vital signs frequently and monitoring airway/oxygen therapy/pulse oximetry. In addition, it is during the postoperative phase that the client will be encouraged to use incentive spirometry to prevent lung stasis, which can lead to pneumonia.
What nursing action(s) is important to limit the risk of intraoperative and postoperative complications?
educating client about postoperative care measuring baseline vital signs having the client void immediately before surgery checking that all diagnostic tests are completed NPO and shaving is not needed for all patients
The nurse needs to understand the teaching-learning process when administering
educational interventions.
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:
in the postoperative stage with occasional pain.
Diagnostic Surgery
makes or confirms a diagnosis such as with a biopsy to check for cancer.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
nasal cannula A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply.
pH 7.45 PCO2 40 mm Hg Base excess or deficit +2 mmol/L Normal ABG findings include a pH of 7.35-7.45, PCO2 35-45 mm Hg, PO2 80-100 mm Hg, and Base excess or deficit +2 mmol/L
In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect?
paralytic ileus
PCA pump
patient controlled analgesic administered intravenously with a machine "The pump is programmed with safeguards to limit the possibility overmedication." The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
poor tissue perfussion
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?
referred pain Referred pain (discomfort perceived in a general area of the body, usually away from the site of stimulation) is not experienced in the exact site where an organ is located. Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage.
Palliative Surgery
surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life
Who is the authority on the presence and extent of pain experienced by a client?
the client
Remission is best defined as:
the presence of a disease with the absence of symptoms. Exacerbation is the reappearance of symptoms of a disease. Disease is a pathologic change in the structure of function of the body or mind. Illness is the response of a person to a disease.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
wheezing