fundemntal
which sound the nurse will hear over the periphery of the major lung fields?
vesicular sounds. These sounds are soft and low-pitched.
which sound The nurse will hear over the trachea.
bronchial sounds over the trachea. These sounds are high-pitched, hollow, and loud.
which sounds The nurse will hear on either side of the sternal border anteriorly and between the scapulae posteriorly.
bronchovesicular. These sounds are moderately loud with a medium pitch.
A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?
"Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.
A nurse is reinforcing teaching for a client about performing range-of-motion exercises of the wrist. To have the client demonstrate adduction, which of the following instructions should the nurse give?
"With your palm facing down, move your wrist sideways toward your thumb." This motion is adducting the wrist. move her wrist 30º to 50º with this motion.
A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?
A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness. Incorrect Answers: A. Muscle tremors are manifestations of hypocalcemia, not hypercalcemia. B. Positive Chvostek's and Trousseau's signs are manifestations of hypocalcemia, not hypercalcemia. D. Numbness and tingling around the mouth and in the extremities are manifestations of hypocalcemia, not hypercalcemia.
A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include? (Select all that apply.)
A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard."
A nurse is collecting baseline data of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?
Below the medial malleolus The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle.
A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?
C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength of pulsations as well as their equality and symmetry in all 4 extremities. Incorrect Answers: A. D. The nurse measures the client's pulse rate at the apical and radial sites. Determination of rate is not a component of peripheral pulse evaluation. B. The nurse does not need to specify details about all pulse points, but the evaluation should include the upper portion of the lower extremities.
A nurse is preparing to collect data about the function of a client's trigeminal nerve or cranial nerve (CN) V. Which of the following items should the nurse gather for the test?
Cotton wisps The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to test recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of CN V, the nurse should ask the client to clench the teeth.
nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?
Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters of the Braden scale for determining a client's risk for developing pressure ulcers.
Women age 30 to 65 years should have a
Pap test every 3 years
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate an underlying infection. This and any other manifestation of infection such as purulent drainage, swelling, warmth, or a strong odor should be reported to the provider. Incorrect Answers: A. Tenderness to touch is an expected finding in a postoperative wound healing by secondary intention. Severe pain might indicate an infection or underlying tissue destruction and should be reported. B. Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of wound healing when the body begins to build the wound bed with new skin cells. This is an expected finding in a postoperative wound healing by secondary intention. C. Serosanguineous drainage, which is made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggests an infection and should be reported.
manifestations of hypocalcemia
Muscle tremors, Positive Chvostek's and Trousseau's and Numbness and tingling around the mouth and in the extremities
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications?
Plasma volume expanders Dextran and albumin are plasma volume expanders. They help correct hypovolemia in emergency situations such as after hemorrhage or burns.
A nurse is reinforcing teaching with a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint?
The nurse should reinforce with the client that the antagonistic muscle group is responsible for the movement of the knee joint by contracting while other muscles relax.
which valve is located in the second intercostal space to the left of the sternum.
The pulmonic valve
Kinesthesia is the
ability to sense the position and movement of body parts without visualizing them
Abstract reasoning develops during
adolescence
Acceptance of body changes should take place during
adolescence.
Ethylene oxide can cause an
allergic reaction in latex-sensitive clients. The nurse should rinse any items that had this type of sterilization with sterile water before use.
Women age 45 years and older should have an
annual mammogram. At age 55, clients might decide to change to every 2 years or continue with annual mammograms.
Peripheral pulse evaluation is for specific clinical indications such as
circulatory impairment to an extremity or during a comprehensive physical examination.
The nurse should collect information about the
client's past health problems during the data-collection phase of the nursing process.
The client should have every 10 years
colonoscopy
The synergistic muscle group is responsible for
contracting in sync to cause the same movement
which nerve the nurse is testing by asking the client to clench his teeth and palpating the masseter muscles for contraction.
cranial nerve V (trigeminal)
using the Rinne and Weber tests and asking the client if he can hear a whisper which nerve are we testing
cranial nerve VIII (vestibulocochlear)
which nerve is The nurse checking when asking the client to vocalize
cranial nerve X (vagus)
by innervates the tongue, by observing a range of tongue movements which verve are we testing
cranial nerve XII (hypoglossal),
Gradual memory loss is a common finding in
dementia rather than delirium
Difficulty with abstract thought is a common finding in
dementia rather than delirium.
Manifestations of hypercalcemia include
depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness.
Verbalization of feelings of hopelessness is a common finding in
depression rather than delirium
According to Erikson, the developmental task for middle adults is
generativity vs. stagnation.
Stress causes an increase in the secretion of cortisol, which can cause
hypertension and hyperglycemia. platelet aggregation( risk of myocardial infarction and stroke).weakens the immune response, placing the client at risk for various infections and worsening the severity of those infections
The appropriate sequence for abdominal data collection is to
inspect, auscultate, percuss, and palpate. This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other data collection for an adult client is: Step 1. Inspection Step 2. Palpation Step 3. Percussion Step 4. Auscultation
Erikson's developmental task of older adults, which is
integrity vs. despair.
Young adults need to develop
intimacy outside of the family
Erikson's developmental task of young adults, which is
intimacy vs. isolation
Concrete thinking develops during
middle childhood.
The nurse should use coffee to test the function
of the olfactory nerve or CN I
The nurse should evaluate the client's popliteal pulse by
palpating behind the knee in the area of the popliteal fossa.
The nurse should evaluate the client's brachial pulse by
palpating in the groove between the biceps and triceps muscles in the area of the antecubital fossa
The nurse should evaluate the client's dorsalis pedis pulse by
palpating on the dorsum of the foot
A full evaluation of peripheral pulses typically includes
palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses.
The antigravity muscle group is responsible for
stabilizing the knee joint.
The skeletal muscle group is responsible for
supporting posture and producing voluntary movement.
Gustation is
the ability to taste
Proprioception is
the awareness of the position of the body.
Discuss the meaning of a common proverb This part of the mental-status examination evaluates
the client's ability to think abstractly.
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?
A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration The nurse should administer the otic medication by holding the dropper 1 cm (0.5 in) above the ear canal. apply pressure to the nasolacrimal duct following the administration of eye drops, not for an otic antibiotic. If necessary, the nurse can apply a cotton ball into the outermost part of the ear canal and remove it after 15 minutes. straighten the ear canal by pulling the auricle down and back prior to administering otic medication for a child who is younger than 3 years of age.
The nurse should identify that the skin can excrete approximately 500 to 600 mL of insensible fluid. This type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin.
A. The kidneys excrete approximately 1,200 to 1,500 mL of urine daily. However, urine is not considered insensible fluid loss. This can increase depending on the client's intake of water. B. The lungs excrete approximately 400 mL of insensible fluid loss each day. C. The gastrointestinal tract loses approximately 100 to 200 mL of fluid each day through feces. However, this is not considered insensible fluid loss.
A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? Middle adults usually feel more comfortable with themselves and cease to make comparisons with others.
A. Young adults should focus on learning to manage a home. B. Young adults should focus on establishing themselves in the adult world. C. Young adults should focus on forming new friendships
A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?
ABGs are drawn to determine the acid-base balance in the arterial blood. This client's pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. The client's PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. The nurse should conclude that the client's elevated pH and decreased PaCO2 indicate respiratory alkalosis. Incorrect Answers: B. Acidosis is determined by measuring a pH lower than the expected reference range of 7.35 to 7.45. This client has a pH of 7.5 and therefore does not have acidosis. C. This client's pH is elevated above the expected reference range of 7.35 to 7.45. Acidosis is presented by a lower pH, usually below 7.35. D. This client's abnormal ABGs do not have a metabolic origin. Metabolic origin is determined by examining the HCO3- levels. The client's bicarbonate is within the expected reference range of 22 to 26 mEq/L.
A nurse is reinforcing teaching with a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?
According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the post-conventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make decisions according to their own beliefs and principles. Incorrect Answers: B. Acceptance of body changes should take place during adolescence. C. Young adults need to develop intimacy outside of the family. D. Concrete thinking develops during middle childhood. Abstract reasoning develops during adolescence.
A nurse is using a portable ultrasound bladder scanner to measure a client's postvoid residual. Which of the following actions should the nurse take?
Apply light pressure to the scanner head once it is in position The nurse should apply light pressure and hold the scanner steadily while pointing it slightly downward toward the client's bladder. urinate 10 minutes before the bladder-scanning procedure. document the amount of urine the client passed at that time. supine position with the head slightly elevated. position the scanner head 2.5 to 4 cm (1 to 1.6 in) above the symphysis pubis.
A nurse is collecting data about a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?
Auscultation of the arteries for bruits
A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take?
C. Position the client supine with the knees in flexion This position reduces any strain that could cause further opening of the incision and worsening of the evisceration. soak sterile gauze in sterile 0.9% sodium chloride irrigation and apply it to the wound.
A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?
Reduced level of consciousness When a client has delirium, the nurse should expect a reduced level of consciousness, sudden memory impairment, illogical thinking, and sleep disturbances.
A nurse is talking with a client whose provider recently informed him that he has terminal pancreatic cancer. When the client expresses that he understands the full impact of this diagnosis, the nurse should identify that he is in which of the following stages of dying?
Depression During the stage of depression, the client has realized the full impact of the loss and might express hopelessness and despair. During the stage of anger, the client shows resistance or blames other people, a higher power, or the situation itself. During the stage of bargaining, the client stalls awareness of the loss by trying to keep it from occurring. During the stage of acceptance, the client will integrate the loss (e.g. by making final arrangements).
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?
Don gloves when entering the room and use hand sanitizer when exiting Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require any staff member who will have contact with the client's environment to don gloves prior to entering the room. Additional precautions such as a gown are required for contact with the client, and a mask and goggles are needed if secretions from the infected area could spray into the worker's face. Since delivering the tray will require contact with the environment, the dietary assistant must wear gloves. Incorrect Answers: A. Anyone who will have actual contact with this client must wear a gown. If the dietary assistant is just placing the lunch tray on the client's table, donning a gown is not necessary. B. MRSA does not spread via droplet or aerosol; therefore, the dietary assistant does not need to wear a mask. D. Infections with multidrug-resistant organisms such as MRSA require special precautions to prevent transmission of the pathogen through contact with the client or the client's environment.
A nurse is assisting with the admission of a client who will undergo a craniotomy. During the planning phase of the nursing process, to which of the following areas should the nurse contribute?
Establishing client outcomes The planning phase of the nursing process includes developing goals and outcomes that help the nurse contribute to the client's plan of care. Incorrect Answers: B. The nurse should collect information about the client's past health problems during the data-collection phase of the nursing process. determine whether the client has met goals during the evaluation phase of the nursing process. The nurse should help identify the client's specific health problems during the data-collection phase of the nursing process.
Eye examination every 2 years This screening is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward.
Eye examination every 2 years This screening is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward. Incorrect Answers: A. Women age 30 to 65 years should have a Pap test every 3 years. B. Women age 45 years and older should have an annual mammogram. At age 55, clients might decide to change to every 2 years or continue with annual mammograms. D. The client should have a colonoscopy every 10 years; testing
A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound?
Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction. Incorrect Answers: A. A hearing aid with low battery power will not work effectively, but it will not whistle. Removing the battery at night can help extend the life of the battery. C. A hearing aid might whistle if the volume is too high, not too low. D. A crack in the ear tube of an in-the-canal hearing aid can impair the hearing aid's amplification of sound; however, it would not cause whistling.
A nurse is reinforcing teaching about how to use an incentive spirometer with a client who is recovering from gallbladder surgery. Which of the following pieces of information should the nurse include in the teaching?
Hold a breath for 5 seconds after goal volume is reached The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia. Incorrect Answers: A. The nurse should instruct the client to inhale slowly to reach goal volume and to decrease the collapse of alveoli in the client's lungs. C. The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths to reduce hyperventilation and fatigue. D. The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake to prevent the risk of atelectasis and pneumonia.
A nurse is collecting data from a client whose calcium level is 7.1 mg/dL. Which of the following findings should the nurse expect?
Hypocalcemia causes hyperactive deep-tendon reflexes and a positive Chvostek's sign, which is a tightening of the muscles in the face when the nurse taps the client's facial nerve. anxiety and confusion, paresthesias numbness and tingling of the fingers and toes as well as around the mouth.
Discuss the meaning of a common proverb This part of the mental-status examination evaluates the client's ability to think abstractly.
Incorrect Answers: A. This part of the mental status examination evaluates the client's attention span. B. This part of the mental status examination evaluates the client's remote memory. C. This part of the mental-status examination evaluates the client's judgment.ndemn
A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task for her age group? think I have done a good job with my children since they are all independent now." According to Erikson, the developmental task for middle adults is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching. The client talking about helping her children achieve independence reflects that she has accomplished this developmental task.
Incorrect Answers: A. This statement relates to Erikson's developmental task of young adults, which is intimacy vs. isolation. C. This statement relates to Erikson's developmental task of older adults, which is integrity vs. despair. D. This statement relates to Erikson's developmental task of older adults, which is integrity vs. despair.
A tracheostomy cover protects the client's airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway.
Incorrect Answers: A. Within the home environment, clean gloves are sufficient. B. Within the home environment, tap water is sufficient for rinsing the inner cannula. C. At home, the client should perform tracheostomy care daily
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
It is best for the client to replace the pouch at a time when the bowel is least active, either after arising in the morning or at least 2 to 4 hours after a meal. Otherwise, the client risks releasing stool while there is no pouch in place. empty the pouch when it is a third to half full replace the pouch twice a week to prevent leakage. If the client has a skin breakdown around the appliance, the pouch will require replacement every 24 to 48 hours for skin treatment. cut an opening in the barrier that is no more than 1/8 inch larger than the stoma.
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
Montgomery straps
General physical condition is a parameter on the
Norton scale, not on the Braden scale
Incontinence is a parameter on the
Norton scale, not on the Braden scale
Mental state is a parameter on the
Norton scale, not on the Braden scale.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the nurse to place the bladder of the cuff when measuring lower-extremity blood pressure. The nurse should auscultate for the blood pressure at the popliteal artery. The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.
A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. Incorrect Answers: A. The mitral valve is located in the fifth intercostal space just medial to the midclavicular line. B. The pulmonic valve is located in the second intercostal space to the left of the sternum. C..
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?
Soak the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions. Tracheostomy care for a client with a new tracheostomy should be performed using surgical asepsis, or sterile technique. The nurse should allow room to insert one to two fingers under the tracheostomy ties so that they are not too restrictive. A cut gauze pad should not be used near a tracheostomy tube because the client can aspirate loose threads. The nurse should use a commercially prepared tracheostomy dressing under the tracheostomy tube.
A nurse is reinforcing teaching with a client about how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Step 1. The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from the mouth Step 2. The client should tilt the head back slightly, and then open the mouth. Step 3. The client should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway. Step 4. After holding a breath for 10 seconds, the client should resume the usual breathing pattern.
Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation.
Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation.
which valve is located in the second intercostal space to the right of the sternum.
The aortic valve is located
A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?
The client holds the cane on the unaffected side. The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability. The nurse should instruct the client to walk by stepping with the affected leg before the unaffected leg to maintain stability. The nurse should instruct the client to place the cane at about 15 cm (6 in) from the side of the foot to provide balance and support. The nurse should instruct the client to hold the cane with the elbow slightly flexed to provide support and stability.
which valve is located in the fifth intercostal space just medial to the midclavicular line.
The mitral valve
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
The nurse should apply the least restrictive priority-setting framework, which assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties are secured again without removing the adhesive strips. Incorrect Answers: A. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed; however, when the client ambulates, the dressings tend to slide. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first. C. Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. Therefore, the nurse should use a less restrictive intervention first. D. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. Therefore, the nurse should use a less restrictive intervention first.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting to decrease the risk of irritation or injury to the mucosa. position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and to promote retention of the enema. hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.
A nurse is preparing to change a dressing on a client who is receiving negative-pressure wound therapy (NPWT). In what sequence should the nurse plan to take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. gently remove the soiled dressing and perform hand hygiene. apply sterile or clean gloves and irrigate the wound to remove debris. apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and provide protection. place foam in the wound bed and cover with a transparent dressing to provide an airtight seal. attach the drainage tube to the transparent dressing and turn on the NPWT unit. Finally, the nurse should check for air leaks and patch the dressing as needed with transparent film.
which valve is located in the fifth intercostal space to the left of the sternum
The tricuspid valve
The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect the client from injury due to wandering
This client is at risk for inadequate nutrition because of the fluid and calorie expenditure from wandering; however, there is another action that the nurse should take first. C. This client is at risk for anxiety because of possible disorientation; however, there is another action that the nurse should take first. D. The client is at risk for escalating anxiety because of possible disorientation; however, there is another action that the nurse should take first.
To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible.
To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. clean gloves. use the non-dominant hand to retract the labia and the dominant hand to insert the suppository. should ease the suppository along the posterior vaginal wall
A nurse is reinforcing teaching for a client about managing her tracheostomy care. Which of the following instructions should the nurse include?
Wear a tracheostomy cover when outdoors A tracheostomy cover protects the client's airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway. Within the home environment, clean gloves are sufficient. tap water is sufficient for rinsing the inner cannula. C. At home perform tracheostomy care daily.
A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client?
Wrap IV tubing with tape Although latex-free products are widely available, the nurse might encounter some products that contain latex such as IV tubing and monitoring cords and devices. The nurse should create a barrier between these items and the client (e.g. by wrapping them in non-latex tape or stockinette). Incorrect Answers: A. The nurse should not snap gloves on and off because these actions disperse any allergens in the gloves into the environment. B. Latex gloves that have "hypoallergenic" on the label still contain latex. Powder and cornstarch are dangerous because the latex allergen attaches to them and becomes an airborne carrier, enabling easy inhalation. The nurse should wear non-latex gloves such as nitrile gloves. C.
A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound?
poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction.
which sound The nurse will hear over the trachea and the bronchi)
rhonchi (gurgling sounds over the trachea and the bronchi) only if the airways are narrowed due to secretions or swelling.
The nurse should use the Snellen chart to test the function of
the optic nerve or CN II.
Documentation of peripheral pulse evaluation should include
the strength of pulsations as well as their equality and symmetry in all 4 extremities. the strength of pulsations as well as their equality and symmetry in all 4 extremities.
the bell of the stethoscope is more effective than the diaphragm in
transmitting blowing or swishing sounds such as those from turbulence in blood vessels.
