N109 Final Study Set

Summarize the effects of anesthetic agents and peristalsis on defecation.

*General anesthetic agents used during surgery cause a temporary cessation of Peristalsis *Direct manipulation of the bowel temporarily stops peristalsis Ie.paralytic ileus

List conditions that may result in painful defecation.

*Hemorrhoids *Rectal Surgery *Rectal Fistula *Abdominal Surgery

List signs and symptoms of fecal impaction

*Oozing stool *Loss of appetite *Nausea and vomiting *Abdominal distention and cramping *Rectal pain

Define fecal impaction and explain how we treat it

Collection of hardened feces that becomes wedged in sigmoid or rectum. Use mineral oil enemas or physical disimpaction

How does Blood Volume affect blood pressure?

Decreases when hypovolemic Increases when hypovolemic Normal blood volume: 5L

What are causative factors for Kussmauls?

Renal Failure, metabolic acidosis, diabetic ketoacidosis

Core Temperature

Temperature of the deep tissues

Which outcome best reflects achievement of the goal, "The patient will expectorate lung secretions with no signs of respiratory complications"? A. Absence of adventitious breath sounds B. Deep breathing and coughing nonproductively C. Drinking 3,000 mL of fluid in the last 24 hours D. Expectorating sputum three times between 3pm and 11pm

*A. Adventitious breath sounds are abnormal breath sounds that occur when pleural linings are inflamed or when air passes through narrowed airways or through airways filled with fluid. The absence of abnormal sounds is desirable.* B. To expectorate secretions, coughing must be productive, not nonproductive. A nonproductive cough is dry, which means that no respiratory secretions are raised and spat out (expectorated) because of coughing. C. Drinking fluid is an intervention that will liquefy respiratory secretions, thus facilitating their expectoration. However, just drinking fluid will note ensure that the secretions will be expectorated. D. Although spitting out sputum reflects achievement of the goal in relation to expectorating lung secretions, it does not address the absence of respiratory complications, which is the ultimate goal of decreasing stasis of respiratory secretions.

A nurse is assessing a postoperative patient. Which complication has occurred when the patient experiences purulent sputum, dyspnea, and chest pain? A. Hypostatic pneumonia B. Hypovolemic shock C. Thrombophlebitis D. Pneumothorax

*A. Postoperative patients often experience hypoventilation, immobility, and ineffective coughing that may lead to stasis of respiratory secretions and the multiplication of microorganisms, causing hypostatic pneumonia. Dyspnea results from decreased lung compliance, chest pain results from coughing and increased work of breathing, and purulent sputum results from the presence of pathogens in sputum.* B. Hypovolemic shock is characterized by tachycardia, tachypnea, and hypotension. C. Thrombophlebitis is characterized by localized pain, swelling, warmth and erythema. If a thrombus breaks loose and travels through the venous circulation the lung (pulmonary embolus) it will cause dyspnea and chest pain, not purulent sputum. D. Pneumothorax is characterized by a sudden onset of sharp pain on inspiration, dyspnea, tachycardia, and hypotension.

List four factors that place a patient at risk for constipation.

*Improper diet *Reduced fat intake *Lack of exercise *Certain medications (opioids for example)

List nursing assessment questions for patient with constipation

*When was your last bowel movements? *Recent or long-standing problem? *Do you have to strain with bowel movements? *Do you have pain with defecation? *Have you recently changed your diet? *Do you use stool softeners?

Explain standard precautions and what the nurse needs to wear.

- Used for care of all patients, in all settings, regardless of risk or presumed infection status, for prevention of infection transmission and apply to contact with blood, body fluids, nonintact skin, mucous membranes, and equipment or surfaces contaminated with potentially infectious materials - Purpose is to break the chain of infection. Includes hand hygiene, PPE, environmental cleaning, and respiratory hygiene/cough etiquette - Wear PPE as appropriate depending on the situation, such as gowns, gloves, masks, eyewear, and other protecting clothing and devices

The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.) Perform chest compressions. Ask someone to bring the defibrillator to the room for immediate defibrilation. Place the patient in the high Fowler's position. Educate the family about the need for CPR

1, 2

Which statement made by the patient indicates an understanding of sleep-hygiene practices? 1. "I usually drink a cup of warm milk in the evening to help me sleep." 2. "If I exercise right before bedtime, I will be tired and fall asleep faster." 3. "I know it does not matter what time I go to bed as long as I am tired." 4. "If I use hypnotics for a long time, my insomnia will be cured."

1. "I usually drink a cup of warm milk in the evening to help me sleep."

The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."

1. "I'll recognize abnormal lumps because they are very painful."

Which are effective leg exercises the nurse should encourage a patient to perform to prevent circulatory complications during the postoperative period? A. Flexing the knees B. Isometric exercises C. Dorsiflexion exercises D. Passive range of motion

1. A. Flexing the knees exert pressure on the veins in the popliteal space; this reduces venous return, which increases, not decreases, the risk of postoperative circulatory complications. B. Isometric exercises strengthen muscles; they do not prevent postoperative circulatory complications. Isometric exercises change the muscle tension but do not change the muscle length or move joints. *C. Alternating dorsiflexion and plantar flexion (calf pumping) contracts and relaxes the calf muscles, including the gastrocnemius muscles. This muscle contraction promotes venous return, preventing venous stasis that contributes to the development of postoperative thrombophlebitis.* D.Passive range of motion exercises are done by another person moving a patient's joints through their complete range of movement.This does not prevent postoperative circulatory complications because the power is supplied by a person other than the patient.To facilitate circulation a patient has to contract and relax muscles actively.

A nurse identifies that a patient's hands are edematous when attempting to apply a pulse oximetry probe. Which action should the nurse implement? A. Attach the probe to one of the patient's toes B. Connect the probe to one of the patient's earlobes C. Wash the patients hand before attaching the probe to the finger. D. Encourage the patient to perform active range of motion exercises of the hand.

1. A. The use of a toe for pulse oximetry can result inaccurate results because of concurrent problems, such as vasoconstriction, hypothermia, impaired peripheral circulation, and movement of the foot. *B. An earlobe is an excellent site to monitor pulse oximetry. It is least affected by decreased blood flow, has greater accuracy at lower saturations, and rarely is edematous. This site is used for intermittent, not continuous, monitoring.* C. Soap and water will not resolve edema. In addition, attaching a pulse oximeter clip sensor to an edematous finger is contraindicated because interstitial fluid interferes with obtaining an accurate oxygen saturation level. D. The cause of the edema must be identified first because range-of-motion exercises may be contraindicated.

A nurse is providing discharge instructions to a client diagnosed with hypomagnesemia secondary to chronic alcohol abuse. The client report frequent acid reflux. Which antacid should the nurse instruct the client to use? A. Tums B. Titralac C. Alka-Seltzer D. Maalox

1. ANSWER: 4 Rational: 1. Tums contains calcium carbonate, which would not help increase the client serum magnesium level 2. Titralac (calcium carbonate) would be an appropriate choice for a client who is experiencing hypocalcemia but would not increase the serum magnesium level. 3. Alka-Seltzer contains sodium bicarbonate, citric acid, and aspirin, which neutralize stomach acid but do not increase the magnesium level. *4. The nurse should instruct the client to consume Maalox for acid reflux because it neutralizes stomach acid and contains magnesium hydroxide/aluminum hydroxide, which increases the client's magnesium intake.*

An older adult client who has been abusing laxatives is being discharged from the hospital. Which manifestations should the nurse instruct the client to report immediately? A. Muscle twitches and constipation B. Fatigue and hypertension C. Bradycardia and hypotension D. Anorexia and abdominal distention

1. ANSWER: C Rationale: A. Muscle twitches and constipation are associated with hypomagnesemia. This client is at risk for hypermagnesemia secondary to laxative abuse. B. Fatigue and hypertension are not manifestations of hypermagnesemia. *C. Magnesium is an active ingredient in many over the counter laxatives. The nurse should instruct the client to report bradycardia and hypotension immediately to a health-care provider because these are signs of hypermagnesemia that require prompt intervention.*

Which clinical manifestations should a nurse associate with the development of hypomagnesemia if observed in a newly admitted client? SELECT ALL THAT APPLY. A. Diarrhea B. Excessive drowsiness C. Positive Chvostek's sign D. Positive Trousseau's sign Hyperactive DTR's

1. ANSWER: C, D, E A. Constipation, not diarrhea is associated with hypomagnesemia because low magnesium levels result in a decrease in intestinal smooth muscle contraction. B. Excessive drowsiness is a sign of hypermagnesemia because high magnesium levels result in depressed nerve impulse transmission *C. The nurse should associate a positive Chvostek's sign with hypomagnesemia because hypocalcemia usually accompanies hypomagnesemia. D. The nurse should associate a positive Trousseau's sign with hypomagnesemia because hypocalcemia usually accompanies hypomagnesemia E. Hyperactive DTR's, usually a sign of hypomagnesemia, occur because a lack of magnesium increases cellular excitability.*

Which assessment should be performed by a nurse to identify whether an older adult client is developing a potentially dangerous side effect of the medication magnesium oxide? A. Nutritional status B. Presence of Constipation C. Input and output D. Deep tendon reflexes

1. ANSWER: D Rationale: A. The client's overall nutritional status would not be affected by magnesium supplements. B. Constipation is associated with hypomagnesemia, not hypermagnesemia. C. Increased urine output would be desired effect of IV magnesium sulfate when treating severe preeclampsia in a pregnant client. *D. When a client is taking magnesium oxide, the nurse should assess for deep tendon hyporeflexia because magnesium supplementation may cause hypermagnesemia, especially in an older adult. An older adult client is at increased risk for electrolyte imbalances*

1. A nurse administers digoxin to an older adult patient diagnosed with atrial fibrillation and systolic heart failure. In addition to the atrial fibrillation, for what other reason should the nurse administer digoxin to the patient? A. To increase the heart rate B. To decrease the potassium loss C. To increase cardiac output D. To decrease urinary output

1. Answer C A. Digoxin does not increase the heart rate B. Digoxin does not decrease potassium loss C. The nurse should administer digoxin not only to treat atrial fibrillation but also to treat heart failure by increasing the cardiac output. An increase in cardiac output promotes diuresis, reducing FVE. The therapeutic effects of digoxin include increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect) D. Digoxin does not decrease urinary output

1. When evaluating a patient being treated for FVE, a nurse determines that the FVE has not resolved based on which finding? A. Level of consciousness improved to alert and orientated B. Decrease in urine specific gravity and increase in urine output C. Bilateral lower extremity edema decreased to trace D. Crackles increased bilaterally in anterior and posterior lung fields

1. Answer D A. Return to a normal level of consciousness reflects resolution of FVE. B. A decrease in urine specific gravity and increase in urine output indicate resolution of FVD, not FVE C. Reduction to scant peripheral edema indicates resolution of FVE D. The nurse should determine that the presence of bilateral crackles indicates that FVE has not resolved. The patient's lungs should be clear bilaterally after the excess fluid has been removed or excreted.

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 5. Use a slow, circular steady massage.

A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible

1. Calls the health care provider and questions the order

1. The nurse caring for a client who has been receiving intravenous diuretics suspect that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? A. Weight loss and poor skin turgor B. Lung congestion and increased heart rate C. Decreased hematocrit and increased urine output D. Increased respirations and increased blood pressure

1. Correct Answer 1 A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess. Test-Taking Strategy: Focus on the subject, fluid volume deficit. Think about the pathophysiology for fluid volume deficit and fluid volume excess to answer correctly. Note that the options, 2, 3, and 4 are comparable and alike

1. The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? A. Stridor B. Occasional pink-tinged sputum C. Respiratory rate of 24 breaths/minute D. A few basilar lung crackles on the right

1. Correct Answer 1 Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider immediately. This is a high-pitched coarse sound that can be heard with the stethoscope over the trachea or without stethoscope. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider. Test Taking Strategy: Note the strategic word immediately. Recall that the primary concern after removal of an artificial airway is the client's inability to maintain a patent airway and breathe independently. Because stridor indicates laryngeal edema and possible airway obstruction, it is the symptom that must be reported immediately.

1. The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? A. Stridor B. Occasional pink-tinged sputum C. Respiratory rate of 32 breaths/minute D. A few basilar lung crackles on the right

1. Correct Answer 1 Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider immediately. This is a high-pitched coarse sound that can be heard with the stethoscope over the trachea or without stethoscope. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider. Test Taking Strategy: Note the strategic word immediately. Recall that the primary concern after removal of an artificial airway is the client's inability to maintain a patent airway and breathe independently. Because stridor indicates laryngeal edema and possible airway obstruction, it is the symptom that must be reported immediately.

1. A client with a urinary retention catheter in place complains of discomfort in the bladder and urethra. What should the nurse do first? A. Notify the physician B. Milk the tubing gently C. Check the patency of the catheter D. Irrigate the catheter with prescribed solutions

1. Correct Answer 3 3. This ensures drainage and prevents bladder distention and other complications. Patency of the catheter should be established before notifying physician. 1. Assessment is necessary before consultation with the physician. 2. Patency of the catheter should be assessed first. This may be necessary if the catheter is clogged. This is usually required when the drainage is viscous rather than liquid. 3. 4. (My computer would not give in!). Irrigation is avoided if possible, because of the associated risk for infection.

1. The nurse is reading a health care provider's progress notes in the client's record and reads that the HCP has documented that the patient has a high insensible fluid loss. The nurse makes a notation that insensible fluid loss occurs through which type of excretion? A. Urinary Output B. Wound drainage C. Integumentary output D. The gastrointestinal tract

1. Correct Answer 3 Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses. Test Taking Strategies: Note that the subject of the question is insensible fluid loss. Note that urination, wound drainage, and gastrointestinal tract losses are comparable or alike in that they can be measured for accurate output. Fluid loss through the skin cannot be measure accurately; it can be approximated.

1. The nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine? A. Clarity B. Viscosity C. Specific gravity D. Glucose and acetone

1. Correct answer 1 1. Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. 2. Viscosity is a subjective characteristic that is not measurable. 3. Specific gravity yields information related to fluid balance. 4. Urinary glucose and acetone levels are not affected by UTi's

1. The immediate objective of nursing care for an overweight, mildly hypertensive client with ureteral colic and hematuria is to decrease which clinical indicator? A. Pain B. Weight C. Hematuria D. Hypertension

1. Correct answer 1 1. Sharp severe pain (renal calculi) radiating toward the genitalia and thigh is caused by urethral distension. The priority is to relieve pain. 2. Although the client is overweight and weight loss would be desirable, it is a long-term goal. 3. Although this may occur, blood loss is usually not massive. 4. Hypertension is not specific to urinary calculi.

1. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes

1. Correct answer 1 A low serum calcium level indicates hypocalcemia. Signs of hypocalcemia include paresthesia followed by numbness, hyperactive tendon reflexes and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability and anxiety, increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Test Taking Strategies: Note that the three incorrect answers are comparable or alike in that they reflect a hypoactivity. The option that is different is the correct option.

1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck and hand veins and decreased urine output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure

1. Correct answer 3 A fluid volume excess is also known as overhydration or fluid overload and occurs the fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. Test Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease.

1. A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse concludes that this is most probably related to: A. Fluid imbalances B. A sedentary lifestyle C. Nervous tension following the procedure D. An interruption in previous voiding habits

1. Correct answer 4 4. An indwelling catheter dilates the urinary sphincters, keeps the bladder empty and short-circuits the reflex mechanism based on bladder distention. When the catheter is removed, the body must adapt to functioning once again. 1 and 3: Although this could cause difficulty in voiding, there an no data presented to draw this conclusion. 2. This would not cause the problem.

1. Which nursing action can best prevent infection from urinary retention catheters? A. Cleansing the perineum B. Encouraging adequate fluids C. Irrigating the catheter once daily D. Cleansing around the meatus periodically

1. Correct answer 4 Cleansing the urinary meatus and adjacent skin removes accumulated bacteria, limiting the possible introduction of microbes into the urinary tract.1.Although cleansing the perineal area is helpful, it is actually the organisms closest to the meatus that gain entry that gain urinary tract first. 2.Although encouraging fluids helps prevent urinary stasis and subsequent infection, the most common source of infection is microorganisms from around the meatus.3.Irrigations require opening the closed drainage system and allowing the entry of microorganisms,, this increases the risk for infection.

1. A client with heart failure has bilateral +4 edema of the right ankle that extends up to the midcalf. The client is sitting in a chair in no evident distress with the legs in a dependent position. The nurse should first: A. Assist the client to the bed B. Request a prescription for support stockings C. Elevate the client's legs on a foot stool D. Take the client's blood pressure

1. Decreasing venous congestion I the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client's legs. It is not necessary for the client to return to bed. The nurse can obtain an order for support stockings after the nurse elevates the client's legs. Vital signs are unnecessary.

Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel? (Select all that apply.) 1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient's room 4. Giving a patient a cup of coffee 5. Monitoring for the effect of the sleeping medication that was given

1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient's room

Which nursing intervention(s) best promote(s) effective sleep in an older adult? (Select all that apply.) 1. Limit fluids 2 to 4 hours before sleep. 2. Ensure that the room is completely dark. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers. 5. Encourage walking an hour before going to bed.

1. Limit fluids 2 to 4 hours before sleep. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers.

1. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle

1. Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using 1, 3, 4. Focus on the subject, testing peripheral response to pain. The nail beds are the most distal of all options and are therefore the most peripheral. All other options may elicit a generalized response, but not a localized one.

1. The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A. A 25-year old woman who runs B. A 36 year old man who has asthma C. A 70 year old man who consumes excess alcohol D. A sedentary 65 year-old woman who smokes cigarettes

1. Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary and smoking cigarettes. Focus on the subject.

1. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which positions should the nurse instruct the client to assume? A. Sitting up in bed B. Side-lying in bed C. Sitting in a recliner chair D. Sitting up and leaning on an overbed table

1. Sitting up and leaning on an overbed table. Eliminate options 1 and 3 first because they are comparable or alike. Next eliminate option 2 because this position will not enhance breathing

A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat a large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.

1. Take brief, 20-minute naps no more than twice a day. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.

1. The client has developed atrial fibrillation, with a ventricular rate of 150 beats /minute. The nurse should assess the client for which associated signs/or symptoms? A. Flat neck veins B. Nausea and vomiting C. Hypotension and dizziness D. Hypertension and headache

1. The client with uncontrolled atrial fibrillation with a ventricular rate more that 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpations, chest pain or discomfort, hypotension pulse deficit fatigue weakness, dizziness, shortness of breath. Focus on the subject, signs of neck veins are normal or indicate hypovolemic, so this option can be eliminated. Nausea and vomiting are associated with vagus nerve activity. Focus on consequences of low cardiac output.

1. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? A. Elevated number of white blood cells in the urine B. Elevated creatinine level C. Decreased hemoglobin level D. Decreased red blood cell count

1. The creatine level is the most specific laboratory test to determine renal function. The creatine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.

1. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar

1. The venturi mask delivers the most accurate oxygen concentration It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease. Options1, 3, 4 because they are comparable or alike in that they are used to provide high humidity.

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. Cranial Nerves 1. XII Hypoglossal 2. V Trigeminal 3. VI Adducens 4. IV Trochlear 5. X Vagus Cranial Nerve Function a. Motor innervation to the muscles of the jaw b. Lateral movement of the eyeballs c. Sensation of the pharynx d. Downward, inward eye movements e. Position of the tongue

1e 2a 3b 4d 5c

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 1. Start oxygen at 2 L/min via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Encourage the patient to use the incentive spirometer. 4. Notify the health care provider.

2

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). what statement made by the patient indicates the need for further teaching? "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles. When I am sick, I should limit the amount of fluids I drink so that I wont produce excess mucus. I will ensure that I receive an influenza vaccine every year, preferably in the fall. I will look for a smoking cessation support group in my neighborhood.

2

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy Tube has become dislodged? Clear breath sounds Patient speaking to nurse SpO2 reading of 96% Respiratory rate of 18 breaths/minute

2

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolp-idem to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours asordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1°C (98.8°F).

2, 1, 4, 3

Which assessment findings indicate that the patient is experienceing an acute disturbance in oxygenation and requires immedieate intervention? 1. Spo, value of 95% 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring 5. Clubbing of fingers

2, 3, 4

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are better than prescription medications because prescription medications can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls. 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."

2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls.

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? 1. "I'll give the baby a bottle to help her fall asleep." 2. "We'll place the baby on her back to sleep." 3. "We put the baby's stuffed animals in the crib to make her feel safe." 4. "I know the baby will not need to be fed until morning."

2. "We'll place the baby on her back to sleep."

Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 12 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

2. Difficulty arousing the patient

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply.) 1. Give patients a cup of coffee 1 hour before bedtime. 2. Plan vital signs to be taken before the patients are asleep. 3. Turn television on 15 minutes before bedtime. 4. Have patients follow at-home bedtime schedule. 5. Close the door to patients' rooms at bedtime.

2. Plan vital signs to be taken before the patients are asleep. 4. Have patients follow at-home bedtime schedule. 5. Close the door to patients' rooms at bedtime.

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for the past year to manage her arthritic pain. The health care provider's order reads as follows: "Hydrocodone APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP.q3h, pr. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain. patient-controlled analgesia:

2. Request to have the order changed to around the clock (ATC) for the first 48 hours.

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

A new medical resident writes an order for oxycodone CR 10 mg POq2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route

2. The time interval

Place the following steps in the correct order for administration of patient-controlled analgesia: 1. Insert drug cartridge into infusion device and prime tubing. 2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry. 3. Demonstrate to patient how to push medication demand button. 4. Secure connection and anchor PCA tubing with tape. 5. Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain. 6. Insert needleless adapter into injection port nearest patient 7. Apply clean gloves. Check infuser and patient control module for accurate labeling or evidence of leaking 8. Program computerized PCA pump as ordered to deliver prescribed medication dose and lockout interval. 9. Attach needleless adapter to tubing adapter of patient-controlled module.

3, 5, 7, 1, 9, 2, 6, 4, 8

A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. "I feel refreshed when I wake up in the morning." 2. "I use soft music at night to help me relax." 3. "It takes me about 45 to 60 minutes to fall asleep." 4. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

3. "It takes me about 45 to 60 minutes to fall asleep."

The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

3. Have the patient relax the foot while lying supine. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

3. Respiratory rate of 8 breaths/min

A patient is being discharged home on an around the clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants

3. Stool softeners

The nurse receives a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding

3. The amount of daily acetaminophen

Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) 1. Initiate oxygen therapy via nasal cannula. 2. Perform nasotracheal suctioning of a patient. 3. Educate the patient about the use of an incentive spirometer. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.

4, 5

The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene. 8. Withdraw catheter.

7, 2, 6, 4, 5, 3, 1, 8

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing, 3. Clear but slightly diminished breath sounds on the right side of the chest 4. Pain score of 2 one hour after the administration of the prescribed analgesic.

1

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's ECO, monitor 3. The patient has clear breath sounds. 4. It has been 3 hours since the patient was last suctioned. 5. The patient has excessive coughing.

1, 2, 5

Which statements from a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply.) 1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 3. "A short nap late in the evening will lead to a more restful night of sleep." 4. "I am going to start eating dinner closer to my bedtime 5. "I will start exercise regularly during the day."

1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 5. "I will start exercise regularly during the day."

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

1. Appearance and behavior

When teaching a patient about trans-cutaneous electrical nerve stimulation (TENS), which of the following represent an accurate description of the non-pharmacological therapy? (Select all that apply.) 1. Turn TENS on before patient feels discomfort. 2. TENS works peripherally and centrally on nerve receptors. 3. TENS does not require a health care provider order. 4. Remove any skin preparations before attaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.

2. TENS works peripherally and centrally on nerve receptors. 4. Remove any skin preparations before attaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.

The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient, observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."

3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a colonoscopy every 2 years? 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55. 4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

How does Viscosity affect blood pressure?

A. Determined by hematocrit. Slows down blood flow when more viscous. Increasing risk of deep vein thrombosis. Hydrate!! When the HCT rises and blood flow slows, BP rises. The heart must work harder to move the viscous blood the blood vessels.

How does Age affect blood pressure?

BP increases with age

How does Cardiac Output affect blood pressure?

Can increase because of increased HR and contractility or can backfire when you have poor left ventricular function and less filling time

1. When assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower leg? A. Aching in the left calf B. Burning in left calf C. Numbness and tingling in the left leg D. Coldness of the left foot and ankle

Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction

Hypothalamus

Controls body temperature

What are causative factors for Apnea?

Deceased patient, head injury, stroke

What are some strategies to increase fluid intake that can be used for patient teaching?

Educate about drinks that act as diuretics Educate about Gatorade (high sugar however) Educate about Pedialyte Educate that it is important to drink water!! 8 glasses per day. You need to stay ahead of the thirst

What are causative factors for Hyperpnea?

Emotional Stress, diabetic ketoacidosis

What are causative factors for Tachypnea?

Fever, Anxiety, exercise, shock

How do fluids affect the character of feces?

Fluid liquefies the intestinal contents, easing its passage through the colon; Reduced fluid intake slows the passage of food through the intestine leading to Increased time of the colon to absorb fluid

What is direct mode of transmission?

From human source to human susceptible host physical contact directly spreading infection by hands, kissing or sexual contact. Contaminated hands touching a patient, kissing someone or sexual contact for example. Usually oral, fecal, or infected lesions or body fluids. Prevention includes washing hands, covering open wounds, avoiding sexual contact, using gloves with body fluids, and again washing hands after contact and removal of gloves.

The last patient on your shift is brought to the ED by a neighbor who noticed her sitting, confused on her front steps. The patient is a 24-year-old female and unable to give a valid history at this time. Admission data include the following: Neurological: Confused Pulmonary: Respirations 28 breaths/min and shallow, lungs clear Cardiovascular: Irregular rapid pulse Gastrointestinal: Hypoactive bowel sounds Musculoskeletal: muscle weakness *The co-assigned nurse identifies a nursing diagnosis of risk for decreased cardiac output related to electrolyte imbalance. What is the electrolyte imbalance that is being presented by this patient?*

Hypokalemia

Describe how each of the following would change and the rational for the change in the presence of deficient fluid volume: Heart Rate Blood pressure Serum Hematocrit Urinary Output Urine Specific Gravity Weight

Increased Heart Rate Decreased Blood pressure Concentration would decrease Serum hematocrit Decreased Urinary output Increased concentration Urine specific gravity Might stay the same or decrease Weight

Define diarrhea

Increased number of stools and the passage of liquid, unformed feces associated with disorders affecting digestion, absorption and secretion

How does Activity and Weight affect blood pressure?

Increased workload of the heart. Ultimately increases BP. Obesity leads to hypertension

How does Stress affect blood pressure?

Increases blood pressure

How does Smoking affect blood pressure?

Increases due to vasoconstriction

What are causative factors for Cheyne Stokes?

Increasing intracranial pressure, brain stem injury

Shivering

Involuntary body response to temperature differences in the body

What are causative factors for Apneustic?

Lesion in brain stem

Thermoregulation

Mechanisms that regulate the balance between lost and heat produced

Name two complications associated with diarrhea.

Metabolic acidosis Hypovolemia Contact dermatitis Maceration

What subjective data would you expect to gain from a patient that describe symptoms of hypocalcemia?

Muscle twitching, cramping, numbness of face, fingers, toes

What is usually the first indicator that an individual needs more fluids?

No direct answer from instructor other than "Thirst is a late sign"

Your co-assigned nurse tells you, "Keep an eye on his breathing okay?" What is the significance of this directive when the patient has hypocalcemia?"

Normal nerve and muscle activity are affected by hypocalcemia. Calcium causes transmission of nerve impulses and contraction of skeletal muscles. Hypocalcemia can cause breathing difficulty

The last patient on your shift is brought to the ED by a neighbor who noticed her sitting, confused on her front steps. The patient is a 24-year-old female and unable to give a valid history at this time. Admission data include the following: Neurological: Confused Pulmonary: Respirations 28 breaths/min and shallow, lungs clear Cardiovascular: Irregular rapid pulse Gastrointestinal: Hypoactive bowel sounds Musculoskeletal: muscle weakness *In light of the patient's confusion, what medication order can you anticipate from the ED health care provider to correct this electrolyte problem? What are your responsibilities in the implementation of the orders?*

Oral potassium preferred. Depends on severity of symptoms if you want to give slow IV potassium (over hours). 6 rights always!

Explain the normal body defenses against infection by flora.

Prevent harmful pathogens to flourish in an area. The GI tract contains pathogens with multiple good functions in the body. The skin and respiratory system has normal flora present that help to control harmful pathogens.

1. The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed lip breathing is to promote which outcome? A. Promote oxygen intake B. Strengthen the diaphragm C. Strengthen the intercostal muscles D. Promote carbon dioxide elimination

Pursed-lipped breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, 3 are not the purposes of this type of breathing.

What are causative factors for Bradypnea?

Sleep, drugs, metabolic disorders, heat injury, stroke

Which lab result represents hypernatremia? a. Potassium 3.1 mmol/L b. Sodium 135 mEq/L c. Potassium 5.5 mmol/L Sodium 155 mEq/L

Sodium 155 mEq/L

What are causative factors for Biot's?

Spinal meningitis, head injury, CNS causes

Basal Metabolic rate

The body at absolute rest

Identify the sites of health care-associated infections.

Three types of HAIs are: 1) Microorganisms from outside the body (exogenous), 2) an alteration of normal body flora inside the body (endogenous), 3) and microorganisms that are introduced into the body during invasive procedures (iatrogenic). · Urinary tract - Foley or straight catheter, Catheter Associated Urinary Tract Infection (CAUTI) · Surgical sites infections - Surgical Site Infection (SSI) · Respiratory tract - Mechanical Ventilation, Contaminated respiratory equipment, Ventilator Associated Pneumonia (VAP), Ventilator Associated Events (VAE) · Bloodstream - IV or central line Central Line Associated Bloodstream Infection (CLABSI), methicillin -resistant Staphylococcus aureus (MRSA) bloodstream events · GI tract - Clostridioides difficile events (C. diff)

Convection

Transfer of heat away by air movement

Describe how you can assess for hypocalcemia without access to a lab.

Trousseau's or Chvostek checks. Weak cardiac contractions: pulse

List assessment questions for patient with diarrhea

When did the diarrhea start? How many stools do you have per day? Watery or explosive? Have you had chills, fever, weight loss Have you taken antibiotics recently? What have you used to alleviate the diarrhea? Have you been out of the country?

What are normal breath sounds and where are they found? Select all that apply a. Bronchial, anterior b. Pleural Friction Rub, anterior c. Bronchovesticular, anterior and posterior d. Vesicular, anterior and posterior e. Wheeze, anterior

a. Bronchial, anterior c. Bronchovesticular, anterior and posterior d. Vesicular, anterior and posterior

A patient's complete blood count (CBC) results are back. Which result demonstrates polycythemia? a. RBC 10 million b. WBC 15,000 c. Platelets 600,000 d. RBC 2.5 million

a. RBC 10 million

Your patient is a 56-year-old female. What is considered a normal Hemoglobin level for this patient? a. 35% b. 15 g/dL c. 11 g/dL d. 50%

b. 15 g/dL

A RN assesses a patient's oxygen saturation by using a pulse oximeter finger probe. The patient has pneumonia that is currently being treated with antibiotics. The first pulse oximeter reading is 88%. Which of the following actions should the RN perform first? a. Administer 100% oxygen and monitor the pulse oximetry until it reaches 95% b. Assess the probe side to ensure accurate placement c. Raise the head of the bed and ask the patient to take a deep breath d. Contact the provider for a chest x-ray

b. Assess the probe side to ensure accurate placement

True or False: A normal creatinine level is 1.9 mg/dL. a. True b. False

b. False

The BMP ordered on the patient results a potassium level of 6.8 mmol/L. How do you interpret this lab result and what could be the cause? a. Hypokalemia; loop diuretic b. Hyperkalemia; ACE inhibitors c. Hypokalemia; diarrhea d. Hyperkalemia; vomiting

b. Hyperkalemia; ACE inhibitors

A patient had a complete blood count with differential test ordered. You asses the white blood cell count results and know that this laboratory test will also assess the count of what other types of WBCs? Select all that apply: a. Thrombocytes b. Neutrophils c. Lymphocytes d. Eosinophils e. Erythrocytes f. Basophils g. Monocytes

b. Neutrophils c. Lymphocytes d. Eosinophils f. Basophils g. Monocytes

A patient's CBC with differential shows an elevated Eosinophil count at 10%. As the RN you know Eosinophils _________________. a. Fight viral infections b. Fight bacterial infections c. Play a role in allergic reactions and parasitic infections d. Play a role in preventing the invasion of foreign substances

c. Play a role in allergic reactions and parasitic infections

Which result in the CBC reflects the protein found on the red blood cell that helps carry oxygen throughout the body? a. MCH b. RDW c. Hct d. Hgb

d. Hgb

What is stridor? a. High pitched crackling sound, inspiration b. Wet or bubbling low pitched sounds, inspiration or expiration c. Breath sounds heard anteriorly and posteriorly, inspiration and expiration d. High pitched whistling with harsh quality, found on inspiration

d. High pitched whistling with harsh quality, found on inspiration

The physician orders a Basic Metabolic Panel (BMP) on the patient. The RN knows this blood test will assess all of the following EXCEPT. a. Sodium b. Glucose c. Potassium d. BUN e. Albumin f. Chloride

e. Albumin

What is Eupnea?

normal breathing

Evaporation

transfer of heat energy when a liquid is changed to a gas

Conduction

transfer of heat from one object to another with direct contact

Radiation

transfer of heat from the surface of one object to the surface of another without direct contact between the two

What is a vehicle of transmission?

· Contaminated items that are then touched or used and spreads the infection. Examples: Contaminated water, food, body fluids (except sweat), and needles. · Prevention of contaminated vehicles: Public water sanitation; clean, sterilize, and contain/cover body fluids; and disposal of sharps into sharps container that prevent retrieval of sharps and is hard sided to prevent needle punctures through the side.

The elderly have an increased risk for infection. Explain.

· Deterioration of immune function increasing susceptibility and slowing the overall immune response. · Decreased lymphocytes, fewer antibodies with shorter duration of fighting ability. · Risks: Poor nutrition, unintentional weight loss, lack of exercise, poor social support, and low serum albumin levels. · Prevention: Flu and pneumonia vaccinations are recommended to reduce their risk for infectious diseases, as well as education on reducing the risk for infection such as proper hand hygiene.

What is droplet mode of transmission?

· Droplets from oral or respiratory infected sources travel about 3 feet and can contaminate objects or enter a susceptible host's airway or open lesion. · Prevention includes coughing etiquette, mask wearing, gown wearing, and maintaining distance from the droplet source.

What is a vector of transmission?

· External transmission or internal transmission. Insects, animals, parasites that carry pathogens to a susceptible host. · Prevention includes pest control, keeping food sources contained, sewer systems, and trash containment and management to keep food sources of rodents away from the immediate population.

What is indirect mode of transmission?

· From a contaminated object to a susceptible host. · Prevention includes regular cleaning of all surfaces in a living space, washing clothes and linens, shampooing hair, careful food handling and preparation, wiping down equipment, and sterilizing equipment. Keep inanimate objects away from infected sources such as hair, neck ties, jewelry etc.

What is airborne mode of transmission?

· Infected aerosolized particles traveling on air currents can enter a susceptible host through their respiratory tract. Medical equipment can cause aerosolized blood. · Prevention includes wearing a properly fitted N95 mask, containment of the air currents in a closed room with negative air flow. Limiting the amount of time you are in an exposed area with a N95 mask also lessens the chances of cross contamination. Avoiding shaking linens or sweeping a room because that can cause particles to be carried on air currents unnecessarily. Instead fold or unfold linens or clothing gently and damp mop.

Explain the normal body defenses against infection by body system defense.

· Intact skin - bactericidal action, forms barrier, sebum · Respiratory tree - cilia, trapping of inhaled microbes in mucus, macrophages · GI tract - secretes antibacterial substances within the walls of the intestine · Eyes - tears and blinking · Mouth - saliva and mucosa · Urinary tract - outward flow of urine 1. Innate immunity and Inflammation · Inflammation-localized fighting against and containment of a pathogen entering an area of the body o Edema from rapid vasodilation (complement cascade) allowing more blood cells in the area to fight the injury, infection, or irritation o Pain from increased pressure on nerve endings from swelling (edema). o Warmth locally or Fever-In systemic response caused by release of pyrogens from destroyed bacterial cells o Phagocytosis-destruction and absorption of bacteria 2. Humoral: B cells produce antibodies 3. Cell mediated - destruction of infected cells by T cells

List two methods of treating the patient with paralytic ileus

· NG intubation · Increase activity

Explain airborne precautions and what the nurse needs to wear.

· Standard PLUS Airborne: - Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. Requires negative pressure airflow room with HEPA filter. - Wear gown, gloves, and N95. Use new mask for each patient encounter.

Explain contact precautions and what the nurse needs to wear.

· Standard PLUS Contact: - Used for direct and indirect contact with patients and their environment. Spread by touching the patient or objects in the room. - Wear gown and gloves. Wash hands before leaving room (wash with soap and water if C. diff contact precautions)

Explain droplet precautions and what the nurse needs to wear.

· Standard PLUS Droplet: - Focus on diseases that are transmitted by large droplets > 5 microns expelled into the air by coughing and sneezing and by being within 3 feet of a patient - Wear gown, mask, and gloves. Wash hands before leaving room.

Explain protective precautions and what the nurse needs to wear.

· Standard PLUS Protective: - For patients that are highly susceptible to infection. Requires private room with positive airflow and HEPA filtration for incoming air. - Wear standard precautions PPE as needed

Lab tests that screen for infection.

· White blood count - WBC · Complete blood count with differential - CBC with differential · Erythrocyte sedimentation rate - Sed rate, also called ESR · Cultures - of urine, and blood. Cultures with gram stain - of wounds, sputum, and throat

An obese patient has limited mobility after an open reduction and internal fixation of a fractured hip. For which human response related to increased blood coagulability should the nurse monitor this patient? A. Muscle deterioration B. Pain in the calf C. Hypotension D. Bradypnea

A. Although muscle deterioration (atrophy) can occur with immobility, it is unrelated to hypercoagulability. Muscle atrophy is the decrease in the size of a muscle resulting from disuse. *B. Immobility promotes venous dilation, venous stasis, and hypercoagulability of the blood, which can precipitate the formation of a clot in a vein of the leg (venous thrombus) and inflammation of the vein (phlebitis).* C. Hypotension, an abnormally low systolic blood pressure (less than 100mmHg) is not related to hypercoagulability precipitated by immobility. D. Bradypnea, abnormally slow breathing (less than 10 per minute), is unrelated to hypercoagulability caused by immobility.

Which clinical manifestation is of most concern when the nurse assesses a patient who has impaired mobility? A. Shallow respirations B. Increased oxygen saturation C. Decreased chest wall expansion D. Gurgling sounds when breathing

A. Although shallow respirations are a concern, they are not as serious as a clinical manifestation in another option. B. Oxygen saturation may be decreased, not increased, with immobility C. Although decreased chest wall expansion is a concern, it is not as serious as a clinical manifestation in another option. *D. Respirations that sound gurgling indicate air passing though narrowed air passages because of secretions, swelling, or a tumor. A partial or total obstruction of the airway can occur, which is life-threatening.*

An unconscious patient who had oral surgery is admitted to the post anesthesia care unit. In which position should the nurse place the patient? A. Prone B. Supine C. Fowler D. Lateral

A. Although the prone position allows for drainage from the mouth, it is contraindicated because lying on the side of the face compresses oral tissues, impedes assessment, complicates oral suctioning, and may compromise the airway. B. The supine position is unsafe. In an unconscious patient, the gag and swallowing reflexes may be impaired, which increases the risk for aspiration as the tongue falls to the back of the oropharynx, occluding the airway. C. The Fowler position is unsafe. An unconscious patient is unable to maintain an upright position. *D. The lateral position facilitates the flow of secretions out of the mouth by gravity, keeps the tongue to the side of the mouth, maintaining the airway, and permits effective assessment of the oropharynx and respiratory status.*

1. A patient has thick tenacious respiratory secretions. Which should the nurse do to liquefy the patient's respiratory secretions? A. Change the patient's position every two hours B. Get a prescription for an antitussive agent C. Encourage the patient to drink more fluid D. Teach effective deep breathing

A. Changing positions will mobilize, not liquefy, respiratory secretions. B. Mucolytics, not antitussives, liquefy respiratory secretions. Antitussives prevent or relieve coughing. *C. A fluid intake of 2500-3000 mL is recommended to maintain the moisture of the respiratory mucous membranes. Adequate fluid keeps respiratory secretions thin so that they can be moved by ciliary action or coughed up and spat out (expectorated).* D.Deep breathing mobilizes, not liquefies, respiratory secretions

A primary health-care provider orders chest physiotherapy with percussion and vibration for a patient. After the primary health-care provider leaves, the patient says, "I don't understand the purpose of this therapy." Which statement should be included in the nurse's response? A. "It eliminates the need to cough." B. "It limits the production of bronchial mucous." C. "It helps clear the airways of excessive secretions." D. "It promotes the flow of secretions to the base of the lungs."

A. Chest physiotherapy promotes, not eliminates, the need for coughing. B. Chest physiotherapy promotes the expectoration of, not limits the production of bronchial mucus. *C. The forceful striking of the skin over the lung (percussion, clapping) and fine, vigorous, shaking pressure the hands on the chest wall during exhalation (vibration) mobilize secretions that that they can be coughed up and expectorated.* D.Chest physiotherapy mobilizes secretions, thus facilitating expectoration and interfering with the flow of secretions to the base of the lung.

1. A nurse evaluates that the patient understood teaching about the purpose of pursedlip breathing when the patient includes which information when explaining it purpose to a relative? A Precipitates coughing B Helps maintain open airways C Decreases intrathoracic pressure D Facilitates expectoration of mucus

A. Deep breathing and guff coughing, not pursed-lip breathing, stimulate effective coughing. *B. Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse.* C. Pursed-lip breathing increases, not decreases, intrathoracic pressure D. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word huff with short, forceful exhalations keeps the glottis open, mobilizes sputum and stimulates cough.

How does Peripheral Resistance affect blood pressure?

A. Determined by the tone of vascular blood vessels. The smaller the lumen of a vessel, the greater the resistance. As resistance rises, arterial BP rises. As vessels dilate, and resistance falls, BP drops

1. A patient's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first? A. Notify the primary health-care provider B. Encourage breathing deeply C. Raise the head of the bed D. Administer oxygen

A. Notifying the primary healthcare provider is premature. The patient's needs must be met first. B. Although encouraging deep breathing might be done eventually, it is not the priority at this time. This may or may not help. Inadequate oxygenation can be caused by a variety of problems other than shallow breathing. *C. A nurse can implement this immediate independent action. Nurses are permitted to treat human responses. Raising the head of the bed facilitates the dropping of the abdominal organs by gravity away from the diaphragm, which permits the greatest lung expansion* D. Obtaining and setting up the equipment take time that can be used for other more appropriate interventions first.

1. A nurse teaches a patient how to use an incentive spirometer. Which projected Patient outcome will support the conclusion that the use of the incentive spirometer was effective? A. Supplemental oxygen use will be reduced B. Inspiratory volume will be increased C. Sputum will be expectorated D. Coughing will be stimulated

A. Patients who use an incentive spirometer may or may not be receiving oxygen. *B. An incentive spirometer provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume and reduces the risk of atelectasis* C. Although sputum may be expectorated after the use of an incentive spirometer, this is not the primary reason for its use. D. Although the deep breathing associated with the use of an incentive spirometer may stimulate coughing, this is not the primary reason for its use.

A nurse assesses the DTR's of a pregnant client who is diagnosed with preeclampsia. The nurse documents what the client's DTRs are "more that expected." Which grade should the nurse assign to this client's DTR response? A. Grade 0 B. Grade 1 C. Grade 2 D. Grade 3 E. Grade 4

ANSWER D Rationale: A. Grade 0 is no response B. Grade 1 indicates a weaker response that normal (hypoactive). C. Grade 2 indicates a normal response *D. When the client DTR's are "brisker than expected," the nurse should document that they are grade 3* E. Grade 4 indicates a brisk, hyperactive response with intermittent or transient sudden brief, jerking contraction of a muscle or muscle group that is often seen in seizures.

What are the advantages/disadvantages of taking *tympanic* temperatures?

Advantages: Easily accessible-requires no position changes Used with patients with tachypnea Very rapid Unaffected by oral intake or smoking Not influenced by environmental temperatures Disadvantages: More variability than with other routes Otitis media and ear wax alter reading Contraindicated in ear surgery Needs correct positioning Must remove hearing aid

What are the advantages/disadvantages of taking *skin* temperatures?

Advantages: Inexpensive Provides continuous monitoring Safe and noninvasive Disadvantages: Measurement lags behind other sites During temperature changes Adhesion impaired by diaphoresis or sweat Reading affected by environmental temp

What are the advantages/disadvantages of taking *rectal* temperatures?

Advantages: More reliable than oral Disadvantages: Embarrassing for patient Contraindicated in diarrhea, rectal disease Risk of rectal perforation Risk of body fluid exposure Reading affected by impacted stool Contraindicated newborns

What are the advantages/disadvantages of taking *temporal artery* temperatures?

Advantages: Very rapid measurement Easy access No risk of injury to patient Disadvantages: Inaccurate with head covering or hair on forehead. Affected by skin moisture

What are the advantages/disadvantages of taking *oral* temperatures?

Advantages: Easily accessible. Comfortable for patient Disadvantages: Need to delay if patient has eaten or drank. Not indicated for patient with oral surgery, Infants.

A nurse is caring for a patient diagnosed with FVD. The nurse recognizes that increased production of aldosterone and ADH caused by FVD would elicit a decrease in which physiological parameter? A. Urine Output B. Blood Pressure C. Serum sodium D. Body temperature

Answer A A. An increase in production of aldosterone and ADH would cause a decrease in urine output. Both aldosterone and ADH promote the conservation of water and sodium and cause a decrease in urine output as the kidneys increase their reabsorption of water and sodium B. Following an increase in the production of aldosterone and ADH, the patient's blood pressure should increase as vascular volume is restored. C. Because sodium reabsorption is also increased by an increase in the production of aldosterone and ADH, the serum sodium does not decrease D. Aldosterone and ADH have no effect on body temperature

A nurse instructing a patient on a low sodium diet should advise the patient that it is appropriate to consume which condiment? A. Mayonnaise B. Barbecue sauce C. Catsup D. Chili sauce

Answer A A. The nurse should advise the patient that it is appropriate to consume mayonnaise as part of a low-sodium diet. Although it is high in fat, 1 TBS of mayonnaise contains approximately 80mg of sodium B. Barbeque sauce is considered a high sodium food and should be avoided in low sodium diets C. Catsup is considered a high sodium food D. Chili sauce is considered a high sodium food

Which urine output value in an adult patient should a nurse associate with the development of FVD? A. 20mL/hr B. 40mL/hr C. 60mL/hr D. 80mL/hr

Answer A A. The nurse should identify a urine output of 20mL.hr as indicative of FVD. The minimal urine output for an adult patient is 30 mL/hr, and the average urine output is 35-40 mL/hr. Dehydration should be considered in any adult with a urine output of less than 30mL/hr B. For an adult patient, 40ml/hr is within the range of average hourly urine output and is not associated with the development of FVD. C. For an adult patient, 60ml/hr is greater than average D. For an adult patient, 80ml/hr is greater than average

A patient presents to an urgent care center after reported 3-day history of nausea and vomiting and diarrhea. A nurse suspects that the patient is severely dehydrated. Which information is most important for the nurse to obtain when assessing this patient? A. Vital signs B. Skin turgor C. Thirst level D. BUN and creatinine

Answer A A. When assessing a patient for FVD, it is most important for the nurse to obtain the patients' vital signs. Although skin turgor , thirst level and renal function are important when assessing a patient with FVD, vital signs are most important to direct the course of therapy and assess for cardiovascular and respiratory manifestations of dehydration. B. Although skin turgor is an important assessment for a patient with FVD, vital sign assessment is the most important. C. Although thirst level is an important assessment for a patient with FVD, vital sign assessment is most important. D. Although BUN and creatinine are important assessments for a patient with FVD, vital sign assessment is the most important.

An older adult patient has had nausea, vomiting and diarrhea for 3 days. Assessment by a nurse reveals dry oral mucosa, amber urine, and decreased skin turgor. Which measurement should the nurse obtain to best determine the patient's current fluid status? A. Respiratory rate B. Temperature C. Blood pressure Pulse oximetry

Answer C A. Although the respiratory rate may be affected by FVD, it would not reveal the patient's fluid status as precisely as decreased blood pressure. B. Although temperature may be affected by FVD, it would not reveal the patients' fluid status as precisely as decreased blood pressure C. To best determine the patient's fluid status, the nurse should assess the blood pressure. The patient has signs and symptoms of FVD (nausea, vomiting, and diarrhea for 3 days; dry oral mucosa; amber urine; and decreased skin turgor). A decrease in blood pressure is the best indicator of FVD related to lack of circulating vascular volume. D. Pulse oximetry should not be affected by the patient's fluid status.

Which manifestations should a nurse identify as the most serious complications associated with hyponatremia? A. Anorexia, nausea, and vomiting B. Generalized weakness, muscle cramps, and twitching C. Lethargy, acute confusion, and decreased level of consciousness D. Tachycardia, weak, thread pulses, and decreased blood pressure

Answer C A. Anorexia, nausea and vomiting are not the most serious complication associated with hyponatremia B. Generalized weakness, muscle cramps, and twitching are not the most serious complications. C. The nurse should identify lethargy acute confusion, and decreased levels of consciousness as the most serious changes associated with hyponatremia. These signs may indicate the development of cerebral edema. Cerebral edema is usually associated with serum sodium levels less than 110 mEq/L and can lead to respiratory arrest and death. D. Not as serious

When assessing the fluid status of a patient should a nurse expect normal fluid intake to compare with output? A. Less than the urine output B. More than the sensible and insensible output C. The same amount as the sensible and insensible output Equal to the urine output

Answer C A. If the patient's fluid intake is less than or equal to the urine output, the patient will develop FVD. Urine output is on measure of sensible fluid loss and does not include insensible losses or other routes of sensible output. B. If the patient's intake is greater than the total fluid output, the patient will develop FVE C. A patient's fluid intake should be approximately the same as fluid output, which includes sensible and insensible fluid losses. D. Fluid output includes sensible and insensible fluid losses. Urine output is one measure of sensible loss and does not include insensible losses or other routes of sensible output

An elderly patient is prescribed Lasix 40 mg by mouth daily for the treatment of CHF. An nurse teaches the patient to observe for signs of potassium imbalance while taking this medication. Which signs should the nurse include in patient teaching? A. Muscle twitches, diarrhea, increased gastrointestinal motility B. Confusion, agitation, muscle twitches C. General muscle weakness, constipation weak thready pulse D. Increased blood pressure and heart rate, constipation

Answer C A. The administration of non-potassium sparing diuretics such Lasix places the patient at risk for hypokalemia. Muscle twitches, diarrhea and increased GI motility are signs of hyperkalemia B. The administration of non-potassium sparing diuretics such as Lasix, places the patient at risk for hypokalemia. Confusion, agitation and muscle twitching are signs of hypernatremia, not hypokalemia. C. The administration of non-potassium sparing diuretics such as Lasix places the patient at risk for hypokalemia. The nurse should teach the patient to observe for general muscle weakness, constipation, and a weak thready pulse, which may indicate the patient potassium level is low D. Increased blood pressure, increased heart rate and constipation are early manifestations of hypercalcemia.

Which intervention should a nurse include when planning care for a confused patient with FVD? A. Explain to the patient the rationale for increasing the fluid intake B. Ensure that the certified nursing assistant maintains fresh ice water at the patient's bedside at all times C. Provide fluids at the patient's bedside at the desired temperature at all times D. Assist the patient in drinking fluids every hour

Answer D A. Explaining the rationale for increasing the fluid intake would not ensure that a confused patient receives the appropriate amount of fluid to meet needs. B. Ensuring that the certified nursing assistant maintains fresh ice water at the patient's bedside at all times is important but does not guarantee that a confused patient will ingest the desired amount C. Providing fluids at the desired temperature at all times is important but does not guarantee that a patient will ingest the desired amount. D. The nurse should plan to assist the confused patient in drinking fluids every hour to ensure that he or she gets the daily recommended fluid intake. Assistance includes reminders to drink and helping the patient in the process of drinking

A nurse is instructing a patient on a high-sodium diet. Which foods should the nurse recommend as part of a high-sodium diet? A. Fish and plain baked potato B. Baked chicken and buttered egg noodles C. Salad with balsamic vinaigrette dressing D. Ham and cheese sandwich

Answer: Ham and Cheese sandwich Sandwich meat and processed cheese are choices with the highest sodium content

1. A client receiving a loop diuretic should be encouraged to eat which of the following foods? SELECT ALL THAT APPLY A. Angel food cake B. Banana C. Dried fruit D. Orange juice E. Peppers

Bananas, dried fruit and oranges are examples of foods high in potassium. Angel food cake, yellow cake, and peppers are low potassium.

A health care provider orders a dietary supplement of calcium and an increase of dietary calcium for their patient. What are some dietary alternatives to suggest to the patient besides milk.

Broccoli, fish, oranges. Requires Vitamin D to absorb, however.