Fundamental 1
A nurse is providing preoperative teaching a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client express concern about the risk of acquiring an infection from the blood transfusion. which of the following statements should the nurse make to the client? "Donate autologous blood before the surgery."
Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? "Using a cuff that is too small will result in an inaccurately high reading."
Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. **The width of the cuff bladder should be 40% of the circumference of the client's arm.
A nurse is admitting a client who has decreasd in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses.
Evaluate pedal pulses. MY ANSWER For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? 1. Increase your intake of refined-fiber foods." 2. "Drink a minimum of 1,000 milliliters of fluid daily." 3. "Take a laxative every day to maintain regularity." 4. "Sit on the toilet 30 minutes after eating a meal."
Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. **Need a coarse-fiber food **minimum of 1,500 mL of fluid to prevent constipation **
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
Notify the provider about the client's decision. Acting as the client advocate, the nurse should support the client in her decision and notify the provider.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? 1. Stand toward the client's stronger side. 2.Assume a narrow stance with feet 15 cm (6 in) apart. 3. Place the wheelchair at a 45° angle to the bed. 4. Place the wheelchair at a 45° angle to the bed.
Place the wheelchair at a 45° angle to the bed .(Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required). **Safely transferring a client from a bed to a wheelchair: the nurse to stand in front of the client toward the side that requires the most support: a wide stance with one foot in front of the other.
Taking temperature for 2-yr-old diarrhea patient.
Temporal **Rectal very accurate, but not for diarrhea. **Tympanic for child, but not ear infection **Oral is not appropriate under 2 yrs
A nurse is demonstrating postoperative deep breathing and coughing exercise to client who will have emergency surgery for appendicitis. Which of the following indicates a lack of readiness to learn by the clients? 1. The client asks the nurse to repeat the instructions before attempting the exercises. 2. The client asks the nurse how often deep breathing should be done after surgery 3. he client reports severe pain. 4. The client tells the nurse that this exercise will probably be painful after surgery.
The client reports severe pain. (A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.)
A nurse on a medical-surgical unit is admitting a client. Which of the follwoing information should the nurse document in the clients's record first? 1. Assessemnt
When caring for this client, the nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision.
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? 1. The nurse washes with her hands held higher than her elbows. 2. The nurse washes from the elbows down to the hands. 3. The nurse uses minimal friction when washing her hands. 4. The nurse washes each part of her hands with 5 strokes.
The nurse washes with her hands held higher than her elbows. (The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.) **Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes. **An important principle of surgical handwashing is to scrub the hands first, then work toward the elbows **Scrubbing is performed with a specially designed and premedicated brush when performing surgical hand-washing. The use of mechanical friction is necessary to decontaminate the skin effectively.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as as secondary prevention? 1. Educating parents of young children about dangers of influenza. 2. Screening groups of older adults in nursing care facilities for early influenza manifestations. 3. Holding a community clinic to administer influenza immunizations. 4. Finding rehabilitation programs for older adults who have complications from influenza.
Screening groups of older adults in nursing care facilities for early influenza manifestations. (Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe).
A nurse is teaching an assistiv e personnel (AP) about proper hand hygiene. Which of the following statement by the AP indicate 1. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands 2. washing my hands I will dry them from the elbows down." 3. I will apply friction for at least 10 seconds while washing my hands." 4. "I will use cold water when I wash my hands to protect my skin from becoming too dry." s an understanding of the teaching?
While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. **Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands. ** friction should be applied for at least 15 to 20 seconds. **Hand hygiene should be performed with warm water. Warm water preserves the protective oil of the skin better than hot water.
