Exam 2 NUR 102

The nursing student is describing moral values to another student. Which statement is correct?

"Moral values give individuals some sense of what is right and wrong."

A nurse is caring for a client who has been prescribed codeine, an opioid medication to relieve severe postoperative pain. Which responsibility does the nurse have to complete when handling opioid medications? Select all that apply.

-Count each opioid medication at the change of each shift. -Maintain an accurate account of the use of the medication. -Record each medication used from the stock supply.

When describing the inflammatory response to a group of nursing students, what would the instructor most likely include as a local effect? Select all that apply.

-Erythema -Edema -Pain

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.

-Exercise increases intestinal tone. -Exercise increases efficiency of the metabolic system. -Exercise increases blood flow to kidneys.

Q: Quality or quantity

-How does the sympton feel, look, or soun? How much of it are you experiencing now.

The nurse is preparing to withdraw medication from an unbroken glass ampule. Which nursing actions are appropriate? Select all that apply.

-Invert the ampule to withdraw medication. -Avoid allowing the needle to touch the outside of the ampule. -Tap the top of the ampule.

Nurses assess clients who have physiologic responses to pain. Which examples of pain response are physiologic responses? Select all that apply.

-Nausea and vomiting -Muscle tension and rigidity Increased blood pressure

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

-Takes furosemide daily -Admits to drinking wine through the evening -Has history of diabetic neuropathy The acronym DAME (Drug/alcohol use, Age-related physiologic status, Medical problems, Environmental) assists the nurse to asses fall risk at home

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

-The client wearing the oxygen around his neck -There is spilled water on the floor -The IV is not infusing at the correct rate The skin is blue-ish color.

Which parts of the syringe and needle must be kept sterile when preparing and administering an injection?

-The needle hub -The needle -Inside the barrel

The nurse is preparing to administer an injection to a client. What factor(s) will the nurse consider when deciding which type of syringe and needle to use for administration? Select all that apply.

-The viscosity of the fluid to be injected. -The volume of the drug that needs to be injected into the client. -The prescribed drug dosage to be injected. -The height and weight of the client receiving the injection. -The location of the body where the drug will be injected.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.

-Upright -Semi-Fowler -Fowler

The nurse is caring for a client who has come to the emergency department reporting chest pain rated at 9 on a scale of 1 to 10. The pain shoots down the left arm and started 45 minutes ago. How will the nurse document this pain in the electronic health record? Select all that apply.

-acute -referred -visceral

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.

-adjust the height of the work area -face in the direction of the activity he is performing -use a wide stance and lift with the large leg muscles

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

-airborne precautions -droplet precautions -contact precautions

The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply.

-cutaneous -acute

Discuss how nurses collaborate with team members to promote safe homes and healthcare environments.

-preventing falls targeted solution tool (TST) -Falls tool kit -Falls prevention training program -Root cause analysis (RCA)

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

-removing clutter from the floor -placing nightlights in the bathroom and hallways -moving the bedroom to the ground floor

The nurse is caring for a client who reports muscular and joint pain after an ankle sprain when playing soccer last week. How will the nurse document this type of pain? Select all that apply.

-somatic -acute

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce the risk of client handling injuries. Which action(s) would the nurse include as contributing to this risk? Select all that apply.

-using uncoordinated lifts -lifting when tired -engaging in repetitive movements -standing for long periods

local effect

1. Effects occurring at the site of administration Ex: pain or irritation at an injection site

irrigate an intermittent infusion device. Which size syringe would the nurse use?

10 mL

A nurse is preparing to irrigate an intermittent infusion device. Which size syringe would the nurse use?

10 mL -The large-barrel syringe is used to decrease pressure during irrigation and hence decrease the risk of catheter damage.

IM injections using the deltoid site require

20- to 25-gauge needle that is between 1 and 1½ inches (2.5 and 4 cm) in length

subcutaneous injection

45 degree angle

The nurse is reviewing the plan of care for several clients who have prescriptions for intravenous medications. The nurse understands that which client is at the highest risk for greater effect of the IV medication?

73-year-old client diagnosed with liver disease

intramuscular injection

90 degree angle

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date.

The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?

A draining abscess poses an infection control risk that is sufficiently addressed with contact precautions. Because there is no obvious risk of airborne or droplet transmission, masks, goggles, and face shields are not warranted.

transmission-based precautions

CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions

Standard Precautions

CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics

The nurse has completed administering medications through an enteral tube used for decompression. What is the appropriate nursing action?

Clamp the tube for at least 30 minutes. -The tube should be clamped or plugged for at least 30 minutes to prevent removing the drugs before they leave the stomach.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?

Deltoid

A 35-year-old has chronic back pain. What condition would exacerbate this client's pain?

Depression

An older adult client tells the nurse about taking a popular, over-the-counter nonsteroidal anti-inflammatory drug (NSAID) daily for arthritic pain. Which question could the nurse ask the client to identify a complication associated with chronic use of this medication?

Do you ever pass dark, tarry bowel movements? -NSAIDs are commonly used for the treatment of pain. NSAIDs are the leading cause of gastrointestinal side effects such as stomach ulcers and bleeding. As such, the nurse asks the client about the presence of dark, tarry stools as this indicates upper gastrointestinal bleeding.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

volume-control set

It is used to administer small volumes of IV medication

The nurse is educating a client on how to self-administer subcutaneous insulin injections. The client asks why the needle must be removed at the same angle as that of insertion. How will the nurse respond?

It minimizes tissue trauma.

A client is prescribed an HMO-CoA reductase inhibitor for the treatment of elevated cholesterol and triglyceride levels. Which education will the nurse provide to the client regarding the medication prescribed?

Liver function and glucose levels will be checked periodically. "Statins" will require the monitoring of glucose levels and liver enzymes periodically since they may cause an elevation of liver enzymes

fidelity

being faithful to work-related commitments and obligations. The ethical principle is best demonstrated by the nurse following the employer's policies by completing the incident report following a medication error.

volume-control set

chamber in IV tubing that holds a portion of the solution from a larger container, not a smaller container

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

changing the soiled dressing

peripherally inserted central line (PICC) suddenly reports itching and flushing

clamp the secondary infusion line which is infusing the antibiotic and notify the primary care provider immediately.

medicial asepsis

clean technique, involves procedures and practices that reduce number and transfer pathogens

The nurse works in a pain clinic and sees clients who have various conditions resulting in pain. A number of modalities are prescribed for the clients' treatments. For which client will the nurse question a prescription for a transcutaneous electrical nerve stimulator (TENS)?

client who is 4 months' pregnant

herper zoster

common cause of hyperalgesia

footdrop

complication resulting from extended plantar flexion

Social justice

concept of fair and just relations between the individual and society and is related to wealth and distribution of goods in a society

altruism

concern for others; it can best be explained by a nurse concerned about how a client will care for self after discharge

Which physiologic change should the nurse take into consideration when administering topical application to older adults?

decreased subcutaneous fat

A nurse is assessing the reading on a volume-control set when administering an IV drug to a client. Which of the following functions is performed by a volume-control set?

eliminates the need for an additional bag of fluid

endogenous opioids

endorphins, dynorphins, and enkephalins that modulate pain; therefore, giving opioids reflects this theory

chronic pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

Otitis media occurs in children because the:

eustachian tube is shorter and straighter.

isometric exercise

exercise in which muscle tension occurs without a significant change in muscle length

isokinetic exercise

exercise involving muscle contractions with resistance varying at a constant rate

timolol

eye drop used to treat glaucoma

A-delta fibers

give rise to bright, sharp, and well-localized pain that is immediately associated with the injury.

A meter-dose inhaler

has a canister that contains medication under pressure

The action of ibuprofen is to:

have an antiprostaglandin effect on the CNS. NSAIDs are generally effective for pain-related tissue damage. The analgesic action of these drugs has antiprostaglandin effects in both the peripheral and central nervous systems.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

into a private room

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

intradermal

client sovereignty model

involves the client making all the decisions without input from the clinician

Synergism

is a drug interaction that increases the drug effect.

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise?

isometric Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension.

shaft

length of the needle

Duty

refers to an obligation to use due care.

A stock supply

remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay.

automated medication-dispensing systems

which contain frequently used medications for that unit, any as-needed (PRN) medications, controlled medications, and emergency medications.

The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

within normal limits

Disequilibrium

would lead to balance problems.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. What question would the nurse ask to assess for complications or side effects of chemotherapy?

"Have your mouth and lips become sore and inflamed with ulcers?"

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

"I have set up this sterile field for your procedure, so please do not touch anything around the tray."

The nurse is conducting discharge teaching for a caregiver and a toddler. Which statement by the caregiver indicates the need for additional teaching?

"I will check my text messages while my child is in the tub."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

"Picture yourself with good posture standing; that is how good lying posture works."

On a preoperative surgical unit, as a standard of care, all clients are swabbed for methicillin-resistant Staphylococcus aureus (MRSA). Prior to his surgery, a nurse notes that a specific client's results have come back positive. the client ask the nurse what this means. What is the nurse's best response?

"These results indicate that you are colonized with MRSA." Colonization occurs when microorganisms are introduced into a body surface, grow and multiply, but do not invade or cause illness

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear."

The nurse has finished teaching a client about medications that have been prescribed for administration. Which client statement reflects that teaching about a piggyback infusion of antibiotics has been successful?

"When I am out of bed the small IV bag must not be lower than the large IV bag."

A client who recently underwent amputation of a leg reports pain in the amputated part. What would be the nurse's best response?

"Your pain is a real experience."

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?

"Your white blood cells have increased in the area."

Endorphins

"morphine within"--natural, opiatelike neurotransmitters linked to pain control and to pleasure.

Which client statements would indicate to the nurse that the client needs additional teaching regarding prn pain medication and management? Select all that apply.

-"The nurse will know when my medication is due and will give it to me automatically." -"If I ask for pain medication, I may become addicted." -"It's better to put up with the pain than deal with side effects of medication." -"I should wait until my pain gets worse before asking for pain medications."

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply.

-Abduction of fingers -Adduction of fingers -Flexion of fingers -Extension of fingers

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

-Communication ability -Development level -Mobility

identify safe risks through assessment to include person and environment.

-Developmental level -lifestyle -mobility -sensory perception -knowledge level -communication ability -physical health state -psychosocial

The nurse is preparing an education session on injury prevention for parents with toddlers. What will the nurse prioritize during this session to help parents to reduce the risk of injury for toddler, given their developmental stage? Select all that apply.

-Safety with stairs -water safety -electric outlook safety -childproof latches

The nurse is caring for a client who reports having "kidney pain from a urinary tract infection" for 3 days. How will the nurse describe this pain when reporting off via SBAR? Select all that apply.

-visceral -acute

The nurse is caring for a client who reports nausea and vomiting for 1 week. How will the nurse document this type of pain? Select all that apply.

-visceral -acute

intradermal injection

15 degree angle

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

WBCs

A normal white blood cell count is 5,000 to 10,000 cells/mm3.

Paternalism

A nurse obtains an order for a bed alarm for a confused client

Which method of pain control is based on the gate-control theory?

Acupuncture

Gate Control Theory

Administering a backrub reflects

Which medication administration task will the registered nurse (RN) appropriately delegate to a licensed practical nurse (LPN)?

Administering blood products, administering intravenous push medication, and flushing through a central venous catheter are not in scope of practice for licensed practical nurses (LPNs)

Root Cause Analysis

An analytical technique used to determine the basic underlying reason that causes a variance or a defect or a risk. A root cause may underlie more than one variance or defect or risk.

Which term describes foreign particles that enter a host and stimulate the body's immune response?

Antigen

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse?

Ask the client "what if" questions to determine level of thought organization.

The nurse is caring for an older client with chronic pain due to osteoarthritis, hypertension, and mild dementia. The client reports blurred vision, and the spouse states, "I'm worried. Today I noticed that there was blood in the stool, and there is more confusion than usual." What is the priority nursing action?

Ask the client and caregiver for a medication history.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

Pattern Theory

Asking the client how sensory stimuli produces pain

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate. Client needs should be assessed before considering physical or pharmacologic restraint.

When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?

Assess the vaginal area.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?

Avoid touching the outer surfaces of the gown.

The nurse is administering a subcutaneous injection of insulin to a client. Which action would the nurse take after choosing the appropriate administration site?

Cleanse the area around the injection site with alcohol.

an advance directive.

Clients communicate their wishes to health care providers by verbally participating in health care decision making and by employing written documents

The nurse is preparing to administer oral medication to a client. Which is the first action the nurse will take?

Compare the medication administration record (MAR) with the written medical order

A nurse is administering medication to a client with a gastrointestinal tube. Which intervention is a recommended guideline for medication administration using this route?

Crush medications to a fine powder and mix with 15 to 30 mL of water

Fracture bedpan

DESIGNED FOR PATIENTS WITH LOWER EXTREMITY FRACTURES

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

The client had orthopedic surgery 2 days ago. Physical therapy is scheduled in 1 hour. During the nurse's rounds, the client reports postoperative pain as mild and denies needing the prescribed oral pain medication. Which nursing action will best aid in mobilizing the client?

Encourage the client to take a dose of the pain medication now.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away.

A nurse is making the bed of a client whose limited mobility prevents her from leaving the bed. What should the nurse do when performing this procedure?

Fan-fold soiled linens as close to the client as possible. Place a bath blanket over the client. Have the client hold onto the bath blanket while you reach under it and remove top linens. Fold linen that is to be reused over the back of a chair. Assist the client to turn toward the opposite side of the bed, and reposition a pillow under the client's head. Fan-fold soiled linens as close to the client as possible.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes. If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action?

Give written instructions to the client and caregivers.

The nurse has provided a hot pack to a client who has been experiencing neck pain. According to the gate control theory of pain transmission, why is this intervention likely to be effective?

Heat stimulates the large-diameter fibers that inhibit pain transmission.

The nurse has provided a hot pack to a client who has been experiencing neck pain. According to the gate control theory of pain transmission, why is this intervention likely to be effective?

Heat stimulates the large-diameter fibers that inhibit pain transmission. -Warmth stimulates large nerve fibers to close the gating mechanism that is thought to be located in substantia gelatinosa cells in the dorsal horn of the spinal cord. As a result, pain impulses from that area are blocked.

A client with a percutaneous endoscopy tube is prescribed the following medication: metoprolol 25mg, phenytoin 100 mg, gabapentin 400 mg and acetylsalicylic acid 81 mg, tube feeding formula at 100 mL/hr continuously. How should the nurse proceed?

Hold the tube for 1 hour before and after medication has been administered

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

Hold your cane on the right side.

S: Severity Scale

How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same?

The nurse provides a cool glass of water to a client with inflamed throat tissue. What condition should the nurse caution the client to avoid when drinking very hot liquids while having an inflamed throat?

Hyperalgesia

The nurse has given a client an injection. How will the nurse prevent an accidental needle stick?

Immediately activate the safety needle and place the syringe and needle into a Sharps container.

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.

Incubation period Prodromal stage Full stage of illness Convalescent period -IN PROBABLY FUN CONVERSTATION

The nurse prepares to administer an intravenous medication. Which action should the nurse perform when administering a medication from an ampule?

Insert the tip of the filter needle into the center of the ampule and invert the ampule.

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client?

Intractable Malignant pain is acute pain episodes, persistent chronic pain, or both associated with a progressive malignant-type process. The etiology for malignant pain is resistant to cure, and the pain may be described as intractable.

The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects?

It activates the immune system.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication.

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider?

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the health care provider's order.

Which nursing action is appropriate in the care of a client with an implanted vascular access device?

Maintain patency by routine flushing with a heparinized solution. -Most central line catheters and implanted vascular devices are flushed with a heparinized solution.

The nurse is caring for a client in protective isolation due to neutropenia as a result of chemotherapy. What priority precaution should the nurse implement in this client?

Monitor client for depression and loneliness

invasion of privacy

Personal names and identities should be concealed or obliterated in case studies or research work

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Pour the liquid into a sterile container within the sterile field.

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Provide a bedside commode and ensure adequate lighting.

P: Provocative or Palliative

Provocative or Palliatate -What causes the sympthoms? what makes them better?

The nurse is preparing to administer an intramuscular (IM) injection into a client. Which procedure should the nurse use to administer the injection?

Pull skin and subcutaneous tissue 1 to 1.5 in (2.5 to 3.75 cm) to one side of the injection site while injecting.

Which technique should the nurse employ when instilling otic medication in an adult ear?

Pull the client's ear up and back.

The nurse is performing an assessment of a client that is experiencing pain after a surgical procedure. What symptoms does the nurse assess based on the pain response?

Pupils are dilated.

A new resident at the memory care unit has been prescribed a nitroglycerin patch. Which action should the nurse take for this resident?

Remove any hair from the upper back before applying the patch.

Which action is the best example of a nurse donning/removing protective equipment properly?

Removing respirator after leaving client's room

Sedation Scale

S = sleep, easy to arouse 1 = awake and alert 2 = slightly drowsy, easily aroused 3 = frequently drowsy, arousable, drifts off to sleep during conversation 4 = somnolent, minimal or no response to physical stimulation

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

Short bones contribute to movement

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Surgical asepsis

invasion phase

Symptoms specific to pathogen and immune response (triggered by mult and spread). Immune response may take 3-5 days to reach protective levels. (multiplication and spread)

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

Tactfully request the provider to input the order into the computerized provider order

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason?

The area is free of major blood vessels and fat.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?

The client exhibits restless, uncharacteristic behavior after receiving the drug.

Which documentation note regarding an assessment of eroding tooth enamel is most appropriate?

The client is at risk for caries due to eroding tooth enamel.

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

The client pushes the walker ahead, following behind it.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

Which nursing strategy should the nurse employ to enhance the teaching/learning process for a client who is noncompliant with inhalers?

The nurse should provide simple written instructions with each medication.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

Reservoir host

The organism that becomes infected by a pathogen and serves as a source of transfer of the pathogen to others.

Pharmacodynamics

The physiologic and biochemical effects of a drug on the body defines

Distribution

The process by which the medication is delivered to the target cells and tissues

metabolism

The process of chemically changing the drug in the body

Ergonimics

The study of workplace equipment design or how to arrange and design devices, machines, or workplace so that people and things interact safely and most efficiently.

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting

Transmission

Transfer, such as of a disease, from one person to another

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding confirms the client has developed an infection?

Urine culture is positive for vancomycin-resistant enterococci (VRE).

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

Use a sterile cotton-tipped applicator to apply the prescription to the site

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention?

Use a tepid bath to relieve inflammation and itching.

ineffective breathing patterns

Use of accessory muscles and shallow breathing are consistent

What is the term for the beliefs held by the individual about what matters?

Values

The nurse has just finished injecting a medication intramuscularly, and needle is still in the client's arm. Which is the correct immediate next step?

Wait 10 seconds and then withdraw the needle

T: Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

R: Region or radiation

Where is the symptom located? Does it spread?

An individual supply

a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes.

Oxymetazoline

a nasal decongestant used to alleviate congestion

piggyback infusion

a parenteral drug is administered in tandem with a primary IV solution.

infectious agent

a pathogen, such as a bacterium or virus that can cause a disease

Suspectible host

a person likely to get an infection or disease, usually because body defenses are weak

Visceral pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera

Biofeedback

a technique that trains people to improve their health by controlling certain bodily processes that normally happen involuntarily, such as heart rate, blood pressure, muscle tension, and skin temperature. -Relaxation, imagery, or breath exercises

gate control theory of pain

a theory of pain perception based on the idea that signals arriving from pain receptors in the body can be stopped, or gated, by interneurons in the spinal cord via feedback from two directions

portal of entry

a way for the causative agent to enter a new reservoir or host

Virulence

ability to produce disease

paralysis

absence of strength secondary to nervous impairment

Transduction

activation of pain receptors

A medication lock

allows instant access to the venous system

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

alongside the bed at the same height

Defamation

an act in which untrue information harms a person's reputation and is therefore not applicable here

portal of exit

any body opening on an infected person that allows pathogens to leave

adjuvent therapy

assisting primary treatment

A nurse needs to administer a subcutaneous injection to a client. How far from the previous injection site to the area should the nurse administer the injection?

at least 1 inch (2.5 cm)

The endogenous opioid theory

based on the fact that nociceptors contain receptors that can bind with neurotransmitters

integrity

based on the honesty of a nurse according to professional standards. In this instance, the nurse reported the occurrence of the missed medication to the charge nurse.

altruism

concern for others; it can best be explained by a nurse concerned about how a client will care for self after discharge.

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact

atrophy

decrease in the size of a body structure

Flaccidity

decreased muscle tone; synonym for hypotonicity

Which component of a syringe's needle does the nurse recognize that refers to width?

gauge

reservoir examples

humans, animals, insects, soil, water

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

mobility status

increased pressure, shearing, and friction can lead to breakdown

Hyperalgesia

increased sensitivity to pain

The nurse assesses that a client uses accessory muscles, breathes shallowly, and has a pulse oximetry reading of 94%. Which nursing diagnosis will the nurse assign?

ineffective breathing patterns

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What identified nursing concern provides the clearest justification for the use of physical restraints during this client's care?

injury risk related to agitation

Ataxia

lack of muscle coordination

A nurse is using an 18-gauge needle to administer medication to a client. The nurse knows that, when compared with a 27-gauge needle, an 18-gauge needle has which feature?

larger diameter For most injections, 18- to 27-gauge needles are used; the smaller the number, the larger the diameter. For example, an 18-gauge needle is wider than a 27-gauge needle. The needle gauge, or the diameter, refers to its width.

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

lowering the height of the bed prior to moving the client

The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed?

miconazole

WHO hand hygiene guidelines

moment 1- Before touching a patient moment 2- Before a clean or aseptic procedure moment 3- After body exposure risk moment 4-after touching a patient moment 5- after touching the patients surroundings

isotonic exercise

movement in which muscles shorten (contract) and move

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?

noncommunicable disease

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance

The lumen

opening of the needle

somatic pain

originating from muscle, bone, joints, tendons, or blood vessels

neuropathic pain

pain from damage to neurons of either the peripheral or central nervous system

perception

pain invloves the sensory process that occurs when stimulus for pain is present

Allodynia

pain sensation produced by an innocuous stimulus such as light touch

referred pain

pain that is felt in a location other than where the pain originates

stationary phase

period of equilibrium; microbial deaths balance production of new cells

prodromal stage

person is most infectious, vague and nonspecific signs of disease

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

place a small pillow under each arm

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

decubitus ulcer

pressure ulcer

Absorption

process by which a medication enters the bloodstream

Certification

process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area -The process of certification involves the attainment and validation of specialized nursing knowledge and skills

Modulation

process by which the sensation of pain is inhibited or modified

turbo-inhaler

propeller driven device that spins and suspends a finely powdered medication

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory?

providing temple massage when head hurts

A client tells a nurse, "I have this pounding feeling on the side of my head, like someone is hitting my head with a hammer." The nurse should identify what characteristic of pain assessment?

quality

bisacodyl

rectal suppository used for softening stool

enkephalins

reduce pain by inhibiting the release of substance P

Autonomy

right to self-determination or acting independently and making decisions

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

scoliosis

An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method?

self-contained packets that hold one tablet or capsule for individual clients

acute pain

short-term, self-limiting, often predictable trajectory; stops after injury heals

focal effects

signs related to the specific area of the brain or spinal cord in which the lesion is located

bevel

slanted portion of the needle that provides access into the vein.

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

slight Trendelenburg

C fibers

slow conducting, dull, poorly localized pain after injury

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as:

spasticity.

cutaneous pain

superficial pain usually involving the skin or subcutaneous tissue

The nurse observes a member of the care team removing a gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?

teach the colleague to let the gown fall away rather than pulling on the sleeves

Neuromatrix Theory

teaching client to remove items from home that remind them of work

surgical asepsis

techniques used to destroy all pathogenic organisms, also called sterile technique

Drugs known to cause birth defects are called:

teratogenic.

orthopedics

the correction or prevention of deformities of the skeleton

Breach of duty

the failure to meet the standard of care. An example of breach of duty would be not performing assessments, appropriate interventions, and notifications of the health care provider

Damages

the harm or injury that occurred to the client. In this situation, it would be the death of the client

Negligence

the harm that results because a person did not act reasonably.

integrity

the honesty of a nurse according to professional standards

Transmission

the pain impulse moves from the level of the spinal cord to the brain

defervescence phase

the phase of fever that occurs when the pyrogen level subsides, the temperature set point stabilizes to lower levels, febrile temperatures feel uncomfortably hot, and sweating becomes profuse

Licensure

the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession—and grants that person the license to do so

Accreditation

the process by which an educational program is evaluated and recognized as having met certain standards.

Credentialing

ways in which professional competence is ensured and maintained.

Hemiparesis

weakness on one side of the body

Causation

when the breach of duty caused the injury. An example of causation would be failure to perform assessment and appropriate interventions when providing client care, and this caused injury to the client.

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?

when the client has disorders that affect the absorption of medications