Fundamentals

how long should a medication be administered in within the scheduled time

30 minutes

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

8 oz ice chips

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with her documentation.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

Acupuncture

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

Air into NPH Air into Regular Draw up Regular Draw up NPH

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

Airborne

A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions

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

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

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

Apply intermittent suction when withdrawing the catheter.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

Assist the client to an upright position.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate lung sounds

A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?

Avocados

what are the adverse effects of opioid analgesia

Bradypnea orthostatic hypotension nausea

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

Check the IV tubing for obstruction

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

Check the client for injuries

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

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

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

Cheddar cheese

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

Clean sutures along the incision site.

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

Compare prescriptions with medications the client received during hospitalization.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

Erythema on pressure points

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water.

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

Fried Egg

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

Gently shake the container of medication prior to administration.

what lab results indicate a client is developing dehydration

HCT 55% serum osmolarity greater than 300 serum sodium 150 urine specific gravity 1.035 elevated serum creatine

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

Have family members wear a gown and gloves when visiting.

what should be the first action of a patient who has pulmonary tuberculosis

Implement airborne precautions

what action should be taken in the plan of care for a patient with hypernatremia

Infuse hypotonic IV fluids

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area?

what are the federally funded health care finances

Medicare Medicaid

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

Notify the nursing manager

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

Otain the pronouncement of death from the provider Remove tubes and indwelling lines Wash the client's body Ask the client's family members if they would like to view the body Place a name tag on the body

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

Role overload

what tests should be performed to test balance

Romberg test heel to toe walk

A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?

Second intercostal space at the left sternal boarder

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question?

The dose

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Thread the IV catheter so that the hub rests at the insertion site.

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?

Use a clock pattern to describe food on the client's plate.

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend?

Use progressive relaxation techniques at bedtime.

A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion.

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

Wrap monitoring cords with stockinette and tape them in place.

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

a client who has asthma

when evaluating a clients neurosensory system, to evaluate stereognosis the nurse should ask the client to close his eyes and identify what

a familiar object she places in his hand

after inspecting the abdomen what should be done next

auacultation

what are appropriate actions ministering enteral feeding via NG tube in a long-term care facility

auscultate bowel sounds assist the client an upright position test the pH of gastric aspirate

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

bladder scan shows 525mL of urine

characteristics of anorexia nervosa

body weight less than 85% of ideal fears being fat feels fat females no menses for atleast 3 consecutive

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

breath sounds

a nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?

bruises on the arms in various stages of healing

what actions should be taken to reduce risk of falls

call light in reach provide nonskid footwear complete fall risk assessment

what are expected findings when assessing the clients skin

capillary refill in 2 seconds thick skin on soles of feet numerous light brown macules on the face

what should be included in a teaching about carbon monoxide poisoning

carbon monoxide binds with hemoglobin in the body

pain, Warmth, edema, induration, red streaking, fever, chills, malaise at IV site

cellulitis

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease in heart rate

what are appropriate interventions for a client who reports losing control of urine when coughing laughing or sneezing

decrease or avoid caffeine avoid the intake of alcohol

what are expected changes in aging

decreased height nail thickening decreased bladder capacity

what are the immomobility effects of respiratory system

decreased respiratory movement, decreased oxygen and carbon monoxide exchange stasis of secretions and decreased and weekend respiratory muscles, atelectasis and hypostatic pneumonia

what are the immomobility of respiratory system

decreased respiratory movement, decreased oxygen and carbon monoxide exchange stasis of secretions and decreased and weekend respiratory muscles, atelectasis and hypostatic pneumonia

client receiving an IV reports pain in the arm, chills, not feeling well. Nurse notes warmth, Dima, and duration, red streaking close to IV site what should the nurse

discontinue the infusion

what to do if a patient experience is cellulitis with an IV

discontinue the infusion and remove the catheter Elevate the extremity apply warm compress 3 to 4 times a day obtain a specimen for culture administer antibiotics, analgesics, antipyretics

what to do if a patient is experiencing phlebitis

discontinued infusion in remove the catheter Elevate the extremity apply warm compress 3 to 4 times a day restart the infusion proximal to the site or another extremity culture the site in catheter if drainage is present

A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?

elevate the head of the client's bed

a helping relationship is established with a client if the communication

encourages the client to express the thoughts and feelings

what is an example of a middle aged adults psychosocial development

expressing concern about the next generation welcome opportunities to be creative and productive become involved with community issues

what are the health care regulatory agencies

joint commission state boards of nursing food and drug administration

what does a sequential compression device SCD do

keeps blood pumping in legs

an okder adult has tenting of the akin on hia forearm. what explains this

loss of adipose tissue dehydration diminished akin elasticity

an older adult has tenting of the skin on his forearm. what explains this

loss of adipose tissue dehydration diminished skin elasticity

foods that are low in fiber and easy to digest, dairy products, eggs, custard, yogurt

low residue diet

a client reports abdominal cramping during a cleansing enema what should the intervention be

lower the enema fluid container, this slows the rate of installation

what are effects of immobility of the cardio vascular system

orthostatic hypotension stasis of blood in legs increased risk of thrombus less fluid volume in circulatory system diminished autonomic response increased oxygen requirements decreased cardiac output, poor cardiac effectiveness, increased cardiac workload

edema, throbbing, burning, pain at the site, increase skin temp, erythema, red line up the arm , slowed rate of infusion is an indication of

phlebitis or thrombophlebitis

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

place a client who has tuberculosis in a room with negative-pressure airflow.

what should be included in a general survey

posture skin lesions speech

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

regulate oxygen via nasal cannula at a flow rate no more than 6 L/min

a client with narcolepsy should do what to help with self management

take naps when feeling sleepy

rehab, learning-self management procedures, strategies are what type of prevention

tertiary

what would be included in a plan of care for a patient with pertussis

wear a mask when providing care within 3ft of the client place a surgical mask on the client if being transported to another unit wear a gown when performing care that involves secretions

what are the findings that indicate a sensorineural hearing loss in the left

weber testing shows lateralization to the right ear no signs of obstruction to the left ear canal Rinne test showing length of time is decreased for ear bone conduction air conduction greater than bone conduction in the left ear

what are appropriate steps for the nurse to take when preparing for a cleansing enema

when the enema solution position the client on their left side with right leg flexed lubricate the rectal tube

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

wrap blankets around all four side rails

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach."

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

"What could I have done to deserve this illness?"

A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document?

"client was found lying on floor."

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

"when descending stair, I will first shift my weight to my right leg."

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while i'm lying in bed."

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this."

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?

A 16 yo client who is married A 27 yo who has schizophrenia An adoptive parent who brings in his 8 yo son A 17 yo mother who brings in her toddler.

A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

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

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

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

Cleanse the wound from the center outward.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with her arms at her side and her feet together.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position.

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?

Insert the IV catheter without using a tourniquet

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

what are expected findings when assessing the thyroid gland

Palpate the thyroid in the lower half of the neck feeling the thyroid ascend when patient swallows finding symmetric extension of the trachea on both sides of the midline

what are expected findings when assessing the thyroid gland

Palpatine the thyroid in the lower half of the neck feeling the thyroid ascend when patient swallows finding symmetric extension of the trachea on both sides of the midline

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

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

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

Place the client's arm in a dependent position.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate

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

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

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift.

what tests should be performed to test balance

Robert test

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

Select a suction catheter that is half the size of the lumen.

A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

Semi-fowler's

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR)

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Skin blanching

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

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

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter?

Swelling and coolness are observed at the IV site

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

Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?

albumin level of 3g/dL

what interventions should be used of an older adult during an exam

allow plenty of time for position changes make sure they have any sensory aids in place allow them to take their time answering questions allow them to use bathroom before beginning

A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

an uneven shape

dry mouth, photophobia, urinary retention are

anticholinergic effects

what interventions should be used to reduce the risk of a dvt for a patient post-op

apply elastic stockings change position frequently

what to do if a patient with an IV has a hematoma

apply pressure after IV catheter removal is warm compress and elevation after the bleeding stops

what are nutritional needs and considerations for older adults

are more prone dehydration need the same amount of vitamins and minerals as the young adults do many need calcium supplements have a slower metabolic rate, need fewer calories need more carbs and fiber reduce intake of fats and empty calories

a client has a fractured femur and a BP of 140/94 what action should be done

ask if the patient is in pain

a client asks to move from the bed to the chair what is the priority action

assess the clients ability to help with the transfer

play activities for a school-aged child

building models video games reading

what should be included in health promotion and primary prevention for a school-aged child

child obesity substance use disorder scoliosis stranger awareness

what findings of a skin assessment require immediate intervention

cyanoisis

characteristics for bulimia nervosa

cycle of binge eating followed by purging lack of control during binges at least two binges per week for at least 3 months

a client scheduled for two physical therapy sessions today. what should the nurse take into consideration for the care of the Muslim client

discuss the daily schedule with a client to make sure the client will have time for prayer

what medications can cause hyperglycemia

diuretics corticosteroids antipsychotics

what should be asked for a older adult who loses weight

do you ear alone or with someone have you started any new meds what have you eaten in the last 24 hour are you on a fixed income

what should be asked for a older adult who loses weight

do you eat alone or with someone have you started any new meds what have you eaten in the last 24 hour are you on a fixed income

what is the first sign of maturation in boys

enlargement of the testes and the scrotum

what should the nurse suggest regarding discipline for a toddler

establish consistent boundaries

intermittent infusion tubing should be changed how often

every 24 hours

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

examine personal values about the issue

involuntary fine motor Tremors, riggity, uncontrollable restlessness, and acute dystonia are

extrapyramidal symptoms

a patient states he is thinking of leaving the hospital against medical advice. the nurse gave him a PRN sedative with his usual meds without him requesting it. this is considered

false imprisonment

what are clinical manifestations of localized versus a systemic infection

fever malaise increase in pulse and respiratory rate

play activity of toddlers should be

filling and emptying containers playing with blocks looking at books

an abdomen assessment shoes distension, protrusion at midline, taut skin and no involvement in flanks. what is the cause of distension

flatus

an abdomen assessment shows distension, protrusion at midline, taut skin and no involvement in flanks. what is the cause of distension

flatus

scoliosis is more common with who and when should screening be done

girls and during adolescents growth spurts

manifestations of hypocalcemia

hand and finger spasms during BP cuff inflation vitamin D deficiency risk of pathologic fractures risk for seizures

what are appropriate actions when initiating a bladder training program

have the client record voting times graduate increase the voting intervals remind the clamp to hold urine until next scheduled time

what is an appropriate intervention for a client who is high risk for aspiration

have them tuck their chin in when swallowing

what interventions should be taught for a client who has multiple risk factors for cardiovascular disease

help clients see benefits of their actions identify clients support system suggest community resources teach stress management strategies

ecchymosis at IV site indicates

hematoma

what type of lesions are considered vesicles

herpes simplex varicella

linear clusters of fluid-contsining vesicles with some crusting

herpes zoster

whole grain such as barley and oats, raw veggies, cabbage, legumes, lentils, black beans are

high in fiber

what instructions should be given to a client who is recovering from a minor musculoskeletal injury of the left lower extremities

hold cane on the right side keep two points of support on the floor after advancing cane, move weaker leg forward

what vaccines are appropriate for young adults 20-35

human papilloma virus measles, mumps, rubella varicella

a client who has a heat stroke will have what

hypotension

what medications should alert the nurse for risk of ototoxicity

ibuprofen, Advil cimetidine, tagamet sunvaststin, zocor amiodarone, cordarone

prior to administering medication what is the highest priority action

identify the clients medication allergies

a client reports severe sore throat, pain when swallowing and swollen lymph nodes. what stage of infection is this

illness

who is at risk for complications from food poisoning

immunocompromised individuals

what nutritional interventions are recommended for older adults

increase calcium and fiber decrease sodium

pallor, local swelling and decrease skin temp around the site, damp dressing, slowed rate of infusion is an indication

infiltration or extravasation

when assessing an adult ear canal with an horoscope what actions are appropriate

insert speculum slightly down and forward do not touch the ear canal with the speculum use the light to visualize the typmanic membrane on a cone shape

when assessing an adult ear canal with an otoscope what actions are appropriate

insert speculum slightly down and forward do not touch the ear canal with the speculum use the light to visualize the typmanic membrane on a cone shape

what is the proper procedures an IV catheter

insert the needle with the bevel up in the angle of 10 to 30 degrees after seeing a flashback of blood lower the how close to the skin to prepare for threading the needle into the vein apply pressure 1.25 inches above the insertion site to remove

what should be included in teaching for a client who is diabetes mellitus about Foot Care

inspect the feet daily use moisturizing lotion on the feet check shoes for any foreign objects

continuous infusion tubing should be changed how often

no more than every 96 hours

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.

normal breath sounds

a client is reporting pain despite analgesia. The nurse can assess the intensity of the Pain by

offering the client a pain scale to measure his pain

clients as risk for food poisoning are instructed to eat and drink what

only pasteurized milk, yogurt, cheese and other dairy products

clients as risk for food poisoning are instructed to eat and drink what

only pasteurized milk. yogurt, cheese and other dairy products

guidelines for measuring respiratory rates

place client in semi-fowlers position rest one arm over abdomen observe one full cycle before counting

a nurse ask a client who is come to the ER reporting severe abdominal pain whether he has nausea and vomiting. the nurse is assessing

presence of Associated symptoms

immunizations and education for minimizing risk factors for illness are what level of care

preventative care

a hospital is conducting a community blood pressure screening in its lobby. what level of care is this

primary

A nurse is caring for a patient with behind the ear hearing aid.

remove before shower

what findings suggest a client with a history of herpes zoster is experiencing post therapetic neuralgia

report of continued pain following resolution of rash

what are early indications of hypoxemia

restlessness tachypnea pallor

what should the nurse examine to assess the patients peripheral vascular system who is post-op knees surgery

skin color edema skin temp

what are expected findings of an older adult during a breast exam

smaller nipples more pendulous nipple inversion

what should you do if a patient experiences infiltration or extravasation

stop being fusion and remove the catheter Elevate the extremity encourage active range of motion apply warm or cold compress depending on solution restart the infusion proximal to the site or another extremity

what is the highest priority intervention for a suspected aspiration of a patient on enteral feeding

stop the feeling to prevent aspiration pneumonia

what are manifestations of hypovolemia

tachycardia syncope decreased skin turgor

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?

talk directly to the client, instead of the interpreter, when speaking

specialized care such as burn or cancer centers are what level of care

tertiary

the intensive care unit, oncology, treatment center and burn center are what level of care

tertiary

a nurse caring for a client with the same religious background should recognize that

the same religious beliefs may influence individuals

what are age related finding when examining the head and neck of an older adult

tooth loss glare intolerance thickening eardrums

a toddler who says no all the time to the mother trying to help him get dressed is doing what

trying to increase her independence

what are expected findings when ausculating and percussing the abdomen

tympany borborgymi

what is an a typical indication of an infection

urinary incontinence acute confusion agitation

a client who is on bed rest should do what to maintain latency of airways

use incentive spirometer

what strategies should be used during a physical exam

use open and closed ended questions reduce environment noise perform the general surgery before the exam

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors

what immunizations are recommended for a middle aged adult 35-65

varicella herpes zoster influenza

what vaccines should be given at the preschool age

varicella polio seasonal influenza

what are the recommended immunizations for adolescents 12-22

varicella human papilloma virus seasonal influenza

what is the highest priority assessment before performing in enteral feeding to a client with an NG Tube

verify the placement of the tube

cardiac rehabilitation and home health care are what levels of care

restorative

what are expected findings of a young adult male clients musculoskeletal system

concave thoracic spine posteriorly concave lumbar spine posteriorly muscles slightly larger on his dominant side

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind."

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

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

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order."

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?"

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

"We need to document the exact medication you were taking because you might be allergic to it."

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?

"We will apply oxygen through a tube in your nose"

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

why is it important to flush the enteral feeding of an NG Tube with internet feedings

water helps clear the tube so it doesn't get clogged

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 meq/L

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

Pressing gently on the tragus of the client's ear.

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

Pupil clarity Visual fields Visual acuity

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

The family member washed out the feeding bag with warm water once every 24 hours.

A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

The nurse opens the sterile field on a wet surface

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

abdominal cramping

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?

administer pain medication 45 min before changing the client's dressing

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

administer the medication with the needle at a 45 degree angle

a client previously stated her chikd is ready to potty train now states that she will post phone the toilet training.. what type of learning domain is this

affective

what are appropriate guidelines when performing endotracheal suctioning for a client

apply suction while withdrawing the catheter use a new catheter for each suctioning attempt limit suctioning to two to three attempts

what actions should the nurse take when providing tracheostomy care

apply the oxygen source loosely your surgical asepsis to remove and clean the inner cannula clean the outer surface in a circular motion from the stoma site outward replace the ties only if they're wet or soiled

a client has a rwctured femur and a BP of 140/94 what action should be done

ask if the patient is in pain

what are barriers to effective communication

asking personal questions offering opinions giving advice giving false reassurance minimizing feelings changing the topic asking why questions or asking for explanations offering judgments responding approvingly or disapprovingly

threatening to put a diaper on a patient if he don't use the urinal properly is considered an

assault

what are interventions for seclusion and restraints

assess restraints every 2 hours assess food, fluids, comfort, and safety and document every 15-30 mins

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

assess the client for orthostatic hypotension

what client is at risk for hypovolemia

client who has heart failure

what directions should be given when testing cranial nerve 5

close your mouth clench your teeth tell me when you feel a touch

what heart sound is the left midclavicular line

closure of the mitral valve closure of tricuspid valve

what is the priority action for a client with a history of falls

complete a fall risk assessment

what are the five stages of grief

denial anger bargaining depression acceptance

what are clinical manifestations fluid overload

distended neck veins increased blood pressure tachycardia shortness of breath crackles in the lungs edema

a client has a low platelet count due to chemo.. what is a priority for measuring vitals

do not measure temp rectally

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

evaluate electrolytes

what are expected findings for a client who has had diarrhea for 4 days

hypotension fever poor skin turgor

what are behaviors of active listening

maintaining an open posture establishing and maintaining eye contact responding positively when giving feedback

what are expected decreases in physical function of a middle age adult

metabolism gastric secretion glomerular function

what should you do during therapy for a patient with MRSA

monitor the clients serum antimicrobial levels

a 82 year old client in ER has temp of 101, pulse 114, respiration of 22. he is restless and skin is warm.. what actions are appropriate

obtain culture specimen before initiating antimicrobials encourage rest assist with oral hygiene frequently increase fluids

a 82 year old client in ER has temp of 101, pulse 114, respiration of 22. he is restless and skin is warm.. what actions are appropriate

obtain filter specimen before initiating antimicrobials encourage rest assist with oral hygiene frequently increase fluids

what are actions for a patient who has had a seizure

place patient on side administer meds as prescribed be prepared to insert airway do not leave client alone during a seizure

what immunizations are recommended for an older adult 65 and older

pneumococcal immunizations eye exam mental health screening DEXA scanning

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

practice sessions

taking courses, reading about bike safety is what kind of prevention

primary

a client has amphetamine overdose and sensory overload what intervention should the nurse implement

provide a private room and limit stimulation

what characteristics should be included when explaining rapid eye movement REM sleep

provides cognitive restoration it is difficult to awake a person vivid dreams are common

how to administer ear drops in an adult patient

pull the auricle upward and outward to open the ear canal apply pressure with the finger to the tragus after administering avoid using cotton ball in the ear canal can cause bacteria

activities for preschoolers should include

puzzles musical toys coloring

what are expected findings when asculatating and percussing the thorax

resonance tactile fremitus bronchovesicular sounds

what action should be performed before preparing to insert an NG tube for a client who requires gastric decompression

review a signal the client can use a feeling any distress lay a towel across the clients chest use a water-based lubricant to reduce complications related to aspiration

expected gross motor skills of a 6 month infant

rolls from back to front nears weight on legs sits unsupported

how to prevent phlebitis

rotate IV site every 72 hours

emergency care and surgery is what type of prevention

secondary

hospital based care in the emergency department or clinical unit are what level of care

secondary

what bed position should the bed be in for a client receiving eternal tube feeding due to dysphagia

semi-fowlers

in order to facilitate effective communication with a school-age child who is seated do what

sit at eye level with a child

during a Neuro exam what are expected findings with aging

some vision and hearing decline slow fine finger movement some short term memory decline

what do you do if a patient experiences fluid overload from an IV

stop and fusion and raise the head of the assess Vital Signs and oxygen saturation adjust the rate as prescribed administer diuretics if prescribed

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

tap just bellow the kneecap

what are clinical manifestations of infiltration

temperature around the IV site is cooler The IV dressing is damp the tissue around the venipuncture site is swollen

21 year old with a sore throat tells doctor he has not seen the doctor since highschool. what screening should be done

testicular exam

a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

wash her hands before and after contact with the client