N500 Assessment 3

ventricular mask

- 24-50% at 4-12 L - delivers the most precise oxygen concentration with humidity added - best for clients with chronic lung disease - tubing must remain free of kinks

nasal cannula

- delivers between 24-44% at a flow rate of 1-6L -Low flow device - use water-soluble gel to prevent dry nares

aerosol mask

- fits loosley around face and neck - 24 - 100% at least 10 L - provides high humidification with oxygen delivery -good only for high flow systems -otherwise air entrainment is too great and FIO2 will be reduced significantly. - useful for clients who have facial trauma, burns, and thick secretions

what mental health disorders are related to heart disease?

- mood disorders - anxiety disorder - PTSD - chronic stress

Nursing actions/considerations for specimen collection

- wait 1 -2 hours after the client eats - obtain specimens early in the morning - use sterile specimen container

What lab tests indicate overhydration?

-Decreased Hct -Decreased Blood osmolarity (less than 280 mOsm/kg) -Decreased blood sodium -Decreased urine specific gravity (less than 1.010) -Decreased electrolytes

elements of documentation

-Factual -Accurate & Concise -Complete & Current -Organized

partial rebreather mask

-delivers a bout 60-65% -Acceptable flow rate 6-11 L - looks like a non-rebreather without any one-way valves -Low flow device -Removal of the one-way valve converts NRB mask into a partial rebreather - make sure client uses nasal cannula during meals - use with caution for clients who have a high risk of aspiration or airway obstruction

early manifestations of hypoxia

-tachypnea -tachycardia -restlessness, anxiety, confusion -pale skin, mucous membranes -elevated BP -use of accessory muscles, nasal flaring, adventitious lung sounds

what are the five elements necessary to prove negligence?

1) duty to provide care as defined by a standard 2) breach of duty by failure to meet standard 3) foreseeability of harm 4) breach of duty has potential cause to harm (combines elements 1 and 2) 5) harm occurs

Normal Lab Range: Magnesium

1.3 - 2.3 mEq/L

Normal Lab Range: Sodium

136 - 145 mEq/L

Normal Lab Range: Phosphorus

2.5 - 4.5 mg/dL

Normal Lab Range: Potassium

3.5 - 5 mEq/L

Nurses should provide tracheostomy tube care every ___ hours to reduce the risk of infection and skin breakdown. Give oral care every __ hours Reposition the client every ___ hours

8, 2, 2

Normal Lab Range: Calcium

8.6 - 10.2 mg/dL

Normal Lab Range: Chloride

97 - 107 mEq/L

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A.Crohn's disease B.Postoperative following an appendectomy C.History of bone cancer D.Hyperthyroidism

A

The nurse completes the assessment and notes that the blood pressure, pulse, and respirations are slightly elevated, and the oxygen saturation via pulse oximetry is 86%. Upon auscultation the nurse notes the patient has this loud high-pitched sound that is obvious on expiration, especially end-expiration. The nurse is completing documentation in the electronic health record (EHR) on this client. How should the nurse document these findings? A. Expiratory wheezes B. Coarse rhonchi/coarse crackles C. Baseline lung/breath sounds D. Diffuse rales/fine crackles

A

The nurse completes the documentation and asks the patient to describe her breathing. The patient states, "I get like this sometimes, but it's not as bad as it was yesterday...<cough>" Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the plan of care? A. Impaired gas exchange B. Activity intolerance C. Sensory impairment D. Ineffective health management

A

The nurse opts to provide teaching on key methods to enhance breathing for this patient. Which nonpharmacologic teaching interventions will be most effective for promoting self-care in a patient with COPD? A. Return demonstration of tripod positioning and use of pursed-lip breathing B. Review caloric intake and encourage the patient to eat one larger meal per day C. Encourage the use of home oxygen only when sleeping or resting D. Teach the patient the signs and symptoms of COPD, with an emphasis on pathophysiology

A

The patient is beginning to have increasing difficulty breathing, and her oxygen saturation via pulse oximetry drops briefly to 84%. The nurse notes the patient is audibly wheezing, has increased use of accessory muscles, and has increasing anxiety. What is the priority nursing intervention? A. Sit the patient up and increase the oxygen flow rate B. Call the provider C. Provide therapeutic touch and soft speech to calm the patient D. Explain to the patient what is happening in clear terms

A

history of bone cancer and hyperthyroidism increases the risk for: A) hypercalcemia B) hypocalcemia C) Crohn's disease

A

A nurse threatens to place an NG tube in a clinet who is refusing to eat. This is an example of what tort? a) assault b) battery c) false imprisonment

A Assault: The conduct of one person makes another person fearful

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A) Assault B) Battery C) False imprisonment D) Invasion of privacy

A By threatening the AP, the AP is committing assault.

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A) collaborating with providers to perform obesity screenings during routine office visits B) ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C) providing specialized intraoperative training in surgical treatments for obesity D) educating acute care nurses about postoperative complications related to obesity

A Identify obesity screenings at office visits as an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings.

A registered nurse acts as nurse coach to provide teaching to patients who are recovering from a stroke. Which statement directs the nurse in performing this role? A) The nurse uses discovery to identify the patients' personal goals and create a plan that will result in change. B) The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. C) The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. D) The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

A A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and grunting sounds. Based on these nonverbal cues, what action will the nurse take next? A) Assess for pain and the need for analgesia. B) Ask the patient if they feel anxious. C) Offer to sit with the patient and listen to their feelings. D) Suggest the patient increase their fluid intake to prevent constipation.

A A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and grunting sounds is most likely communicating pain. The nurse should clarify this nonverbal behavior.

A nurse is preparing a teaching plan for a patient with asthma on the use of an inhaler. What teaching method is most appropriate for this patient? A) Demonstration B) Lecture C) Discovery D) Panel session

A Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient-teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions.

The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene? A) "I am sure everything will be fine; you have nothing to worry about." B) "When you return from surgery, you'll need to cough and deep breathe." C) "Many people on this unit have had that procedure with good success." D) "You seem fearful, can I answer any questions about the procedure?"

A Telling a patient that everything will be fine is a cliché. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition.

A public health nurse is leaving the home of a young mother who has an infant with special needs. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response? A) "New mothers need support." B) "The lack of a father is difficult." C) "How are you today?" D) "It is a very sad situation."

A The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. "How are you today?" is dismissive of the neighbor's question.

A primary nurse is preparing a discharge plan for a patient who has been hospitalized following a double mastectomy. Which statement is most appropriate for the nurse to use in the termination phase of the therapeutic relationship? A) "Let's review the progress you've made in meeting your goals." B) "I'd like to review your medication schedule with you." C) "I need to document today's teaching session in the electronic health record." D) "Should we include your family in today's session?"

A The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning correlates with the termination phase of a therapeutic relationship and the progress toward the patient's goals are reviewed.

charting by exception

A method of charting in which nurses only provide notes if there a deviations from a patient's norm or baseline

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (select all that apply) A) make sure the surgeon obtained the client's consent B) witness the client's signature on the consent form C) explain the risks and benefits of the procedure D) describe the consequences choosing not to have the surgery E) tell the client about alternatives to having the surgery

A, B it is the nurse's responsibility to verify that the surgeon obtained the client's consent it is the nurse's responsibility to witness the client's signing of the consent form, and to verify that they are consenting voluntarily and appear to be competent to do so. the nurse should also verify that the client understands the information the surgeon provided

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply) A) Apply the oxygen source loosely if the SpO2 decreases during the procedure B) use surgical asepsis to remove and clean the inner cannula C) clean the outer cannula surfaces in a circular motion from the stoma site outward D) replace the tracheostomy ties with new ties E) cut a slit in the gauze squares to place beneath the tube holder

A, B, C replace tracheostomy ties if they are wet or soiled. use commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares open can loosen lint or gauze fibers the client could aspirate.

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply) A) home health care B) rehabilitation facilities C) diagnostic centers D) skilled nursing facilities E) oncology centers

A, B, D restorative health care involves intermediate follow-up care for restoring health and promoting self care. Examples include home health care and cardiac rehabilitation centers.

A nurse is preparing to perform endotracheal suctioning to a client. The nurse should follow which of the following guidelines? (Select all that apply). A) apply suctioning while withdrawing the catheter B) perform suctioning on a routine basis every 2 to 3 hours C) maintain medical asepsis during suctioning D) use a new catheter for each suctioning attempt E) apply suction for 10 to 15 seconds

A, D, E suction the client's airway only as needed, because suctioning is not without risk. use surgical asepsis when performing endotracheal suctioning,

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (select all that apply) A) repeat the details of the prescription back to the provider B) have another nurse listen to the telephone conversation C) obtain the provider's signature on the prescription within 24 hours D) decline the verbal prescription because it is not an emergency situation E) tell the charge nurse that the provider has prescribed morphine by telephone

A,B,C

The nurse coach at a cardiac rehabilitation office is meeting with a patient who has learned they have heart failure. Which nursing actions might the nurse coach include in coaching sessions for this patient? (Select all that apply.) A) Provide education based on the patient's personal goals. B) Explore the patient's readiness for change. C) Assist the patient to determine progress toward goals. D) Direct the patient to exercise daily. E) Identify goals for the patient.

A,B,C The nurse coach facilitates change or development that assists the individual to cope with health challenges. The nurse coach establishes a partnership with the patient to support the patient to identify and work toward the patient's personal agenda and goals; nurse coaches do not use teaching and other strategies directed by the nurse as an expert. A, b, and c are patient-driven, person-centered interventions to educate and empower the patient. D and e are interventions identified and directed by the nurse, not by the patient, which is not part of the coaching process.

The patient has returned to baseline respiratory function and has received the annual influenza vaccine (flu shot). Which of the following parameters must be in place before discharging a patient with COPD home? Select all that apply. A. Correct return demonstration of all inhaled and oral medications B. Ability to complete activities of daily living with frequent rest periods C. Effective expectoration of secretions using breathing and coughing techniques D. Articulation of when to call the provider for follow-up and/or intervention E. Oxygen saturation via pulse oximetry >98% on room air

A,B,C,D

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply) A) medication error B) needlesticks C) conflict with the provider and nursing staff D) omission of prescription E) missed specimen collection of a prescribed laboratory test

A,B,D Report a conflict with the provider and nursing staff to the charge nurse or nursing manager Report missed specimen

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply) A.Restlessness B.Tachypnea C.Bradycardia D.Confusion E.Hypertension

A,B,D,E

During a nursing staff meeting to discuss delayed documentation, the nurses unanimously agree that they will ensure all vital signs are reported and charted within 15 minutes following assessments. This decision is consistent with which characteristics of effective communication? Select all that apply. A) Group decision making B) Group leadership C) Group power D) Group identity E) Group patterns of interaction F) Group cohesiveness

A,D,E,F Solving problems involves group decision making; ascertaining the task is important and agreeing to complete the task on time is characteristic of group identity. Group patterns of interaction involve honest communication and member support; cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and appropriately used to accomplish group outcomes.

Delegate the following to an AP or PN: 1) monitoring findings 2) ADLs 3) specimen collection 4) vital signs 5) suctioning 6) reinforcing teaching 7) performing tracheostomy care 8) inserting urinary catheter 9) intake and output 10) checking NG tube for patency 11) positioning 12) administering medication

AP: - ADLs - intake and output - specimen collection - vital signs (for stable clients) - positioning All others - PNs

What are the ABCs of heart health

Appropriate aspirin therapy Blood Pressure control Cholesterol control

A nurse on a medical-surgical unit is caring for a group of clients. For which of the clients should the nurse expect to receive a prescription for fluid restriction? A.A client who has a new diagnosis of adrenal insufficiency B.A client who has heart failure C.A client who is receiving treatment for diabetic ketoacidosis D.A client who has abdominal ascites

B

A nurse tells a coworker that they believe the client has been unfaithful to their partner, is: A) breach of confidentiality b) defamation of character

B

•Scenario: Joan McIntyre, age 72, has been admitted to the medical unit with an acute exacerbation of chronic obstructive pulmonary disease (COPD). This is the fifth time she has been in the hospital this year. She is receiving supplemental oxygen and multiple medications to support her breathing. Her activity level is decreased, and she is reporting fatigue. Which assessment should the nurse prioritize in caring for this patient? A. Auscultation of lung/breath sounds and oxygen saturation via pulse oximetry B. Vital signs: temperature, pulse, respiration, blood pressure C. General history: subjective and objective D. Cardiac assessment: heart sounds, peripheral pulses

B

A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A) charge nurse B) RN c) PN d) AP

B Although a charge nurse can provide all of the care this client requires, administrative responsibilities might prevent the close monitoring and assessment of the client's needs

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A) monitoring evidence-based practice for clients who have a specified diagnosis B) ensuring that health care providers comply with regulations C) setting quality standards for accreditation of health care facilities D) determining whether medications are safe for administration to clients

B Identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations

A nurse is caring for a client who is having difficulty breathing. The client is laying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A.Increase the oxygen flow B.Assist the client to fowlers position C.Promote removal of pulmonary secretions D.Obtain a specimen for arterial blood gas

B Think ABC approach (airway, breathing, circulation) with dyspnea (difficulty breathing).

A nurse is caring for a competent adult who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not". The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication that the client has not requested along with the scheduled morning medication. Which of the following torts is the nurse about to commit? A) assult b) false imprisonment c) negligence d) breach of confidentiality

B administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment, because the client neither requested nor consented to receiving the service

A nurse develops a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? A) "This agreement forms a legal bond between the two of us to achieve your weight goals." B) "This agreement will motivate the two of us to do what is necessary to meet your weight goals." C) "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." D) "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

B A contractual agreement is a pact two people make, setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment.

A nurse says to their nurse manager, "I need the day off, and you didn't give it to me!" The manager replies, "I wasn't aware you needed the day off, and it isn't possible since staffing is inadequate." How could the nurse best modify the communication for a more positive interaction? A) "I placed a request to have 8th of August off for a doctor's appointment, but I'm scheduled to work." B) "Could I make an appointment to discuss my schedule with you? I requested the 8th of August off for a doctor's appointment." C) "I will need to call in on the 8th of August because I have a doctor's appointment." D) "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

B Effective communication involves sending clear, nonthreatening, and respectful information to the receiver. The nurse identifies the subject of the meeting and determines a mutually agreed upon time.

A nurse is caring for a patient who is admitted to the hospital with traumatic injuries sustained in a motor vehicle accident. While hospitalized, the patient's spouse tells the patient that their house flooded, damaging their belongings. When the nurse notes that the patient is visibly upset by this news, the nurse suggests which type of counseling? A) Long-term developmental B) Short-term situational C)Short-term motivational D) Long-term motivational

B Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health.

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? A) Promoting health B) Preventing illness C) Restoring health D) Facilitating coping

B Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote and maintain wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations.

The nurse has taught a patient with diabetes how to administer subcutaneous insulin injections. Which is the best strategy to evaluate if the teaching goal has been met? A) Ask the patient the insulin dose and times of day they will administer insulin. B) Observe the patient's technique in drawing up and administering insulin. C) Have the patient explain the skill they have just learned. D) Document the teaching session in the patient's electronic health record.

B The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is ensuring the learner meets the outcomes stated in the teaching plan, in this case, by demonstrating the psychomotor skill.

A nursing student is preparing to administer morning care to a patient. What question by the student is most important to ask? A) "Would you prefer a bath or a shower?" B) "May I help you with a bed bath now or later this morning?" C) "I will be giving you your bath. Do you use soap or shower gel?" D) "I prefer a shower in the evening. When would you like your bath?"

B The nurse should ask permission to assist the patient with a bath. This allows for patient preferences and consent for care that involves entering the patient's personal space.

Which of the following are components of the five rights of delegation? (select all that apply) A) right place B) right supervision and evaluation C) right direction and communication D) right documentation E) right circumstances

B, C, E

A nurse is reviewing the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (select all that apply) A) preferred provider organization (PPO) B) Medicare C) long-term care insurance D) exclusive provider organization E) Medicaid

B, E Medicare and Medicaid are federally funded

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply) A.Cover errors with correction fluid and write in the correct information B.Put the date and time on all entries C.Document objective data, leaving out opinions D.Use as many abbreviations as possible E.Wait until the end of the shift to document

B,C

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply) A.The roommate ambulates independently B.The client ambulates wearing slippers over antiembolic stockings C.The client uses a front-wheeled walker when ambulating D.The client had pain medication 30 minutes ago E.The client is allergic to codeine F.The client ate 50% of breakfast this morning

B,C,D These are all needed to complete this particular assignment safely

A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse include? (Select all that apply) A) a single Electonic records password is provided for nurses on the same unit B) family members should provide a code prior to receiving client health information C) communication of client information can occur at the nurse's station D) a client can request a copy of their medical record E) a nurse can photocopy a client's medical record for transfer to another facility

B,C,D,E

A nurse is planning teaching strategies in the affective domain of learning for patients with alcohol use disorders. Which teaching-learning activities will the nurse use? Select all that apply. A) Preparing a lecture on the harmful long-term effects of alcohol on the body B) Asking the patient to discuss reasons people with alcohol use disorders drink and exploring other methods of coping with problems C) Requesting that patients perform a return demonstration for using relaxation exercises to relieve stress D) Helping patients to reaffirm their feelings of self-worth and relate this to their alcohol use disorder E) Using a pamphlet to discuss the tenets of the Alcoholics Anonymous program with patients F) Reinforcing the mental benefits of gaining self-control over a substance use disorder

B,D,F Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill.

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A.Starting an IV infusion of 0.9% sodium chloride B.Consulting with dietician to increase intake of potassium C.Initiating continuous cardiac monitoring D.Preparing the client for a gastric lavage

C

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during break time. Which of the following actions should the nurse take? A) alert the American Nurses Association B) fill out an incident repot C) report the observations to the nurse manager on the unit D) leave the nurse alone to asleep

C Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has duty to report the situation immediately to the nurse manager * Incident reports are also called variance report or occurrence reports

A nurse uses restraints on a competent client to prevent them from leaving the health care facility. This is an example of what tort? a) assault b) battery c) false imprisonment

C False imprisonment is confined or retrained against their will

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A.Updating the plan of care for a patient who is post-operative B.Reinforcing teaching with a client who is learning how to walk with a quad cane C.Reapplying a condom catheter for a client who has urinary incontinence D.Applying a sterile dressing to a pressure injury

C The application of a condom catheter is a noninvasive, routine procedure that can be delegated to an AP

A nurse in preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? A.Input and Output for the shift B.Blood pressure from the previous day C.Bone scan scheduled for today D.Medication routine from the medication administration record

C The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A) "I'd rather have my brother make decisions for me, but I know it has to be my wife." B) "I know they won't go ahead with the surgery unless I prepare these forms." C) "I plan to write that I don't want them to keep me on a breathing machine." D) "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arises

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A.Creating a plan of care for a client who is recovering following a stroke B.Assessing a pressure injury on a client who is on bedrest C.Providing nasopharyngeal suctioning for a client who has pneumonia D.Teaching a client who has asthma to use a metered-dose inhaler

C This is in the scope of practice of a PN (LPN). All other answers are outside the scope of care of a PN.

A nursing student is nervous and concerned about working at a clinical facility. Which action would best decrease anxiety and help ensure successful delivery of patient care? A) Determining the established goals of the institution B) Ensuring that verbal and nonverbal communication is congruent C) Engaging in self-talk to plan the day and decrease fear D) Speaking with fellow colleagues about how they feel

C By engaging in positive self-talk, or intrapersonal communication, the nursing student can plan the day, decrease fear and anxiety, and enhance clinical performance.

A nurse is teaching an adult patient how to care for their new ostomy appliance. Which evaluation method is most appropriate to confirm that the patient has learned the information? A)Ask Me 3 B) Newest Vital Sign (NVS) C) Teach-Back Method D) TEACH acronym

C The Teach-Back Method tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The NVS is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process.

A nurse in the diabetes clinic initiates education for a patient with a new diagnosis of diabetes. The nurse notes the patient has completed 2 years of college. What action does the nurse select for the initial teaching session? A) Providing the patient with handouts related to blood-glucose management B) Demonstrating the use of the blood-glucose monitor and tool to record blood-glucose readings C) Assessing the patient's knowledge of diabetes and their ability to interpret the health information D) Explaining the dietary restrictions including foods that are prohibited

C While the nurse takes the patient's level of education into account when providing teaching, the first step is assessing the patient's knowledge and readiness to learn. The nurse would not provide handouts or AV material without reviewing the information and assessing the patient's understanding. Discussing or demonstrating psychomotor skills, an intervention, is performed after assessment.

COPE Model

C - creativity O - optimism P - planning E - expert information

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? Select all that apply) A.Distended neck veins B.Hyperthermia C.Tachycardia D.Syncope E.Decreased skin turgor

C,D,E

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply) A.Apply petroleum jelly around and inside the nares B.Remove the nasal cannula during mealtimes C.Check the position of the nasal cannula frequently D.Report any nausea of difficulty breathing E.Post "No Smoking" signs in prominent locations

C,D,E

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after hearing the plan of care. How does the nurse best respond? Select all that apply. A) Fill the silence with lighter conversation directed at the patient. B) Use the time to perform the care that is needed uninterrupted. C) Discuss the silence with the patient to ascertain its meaning. D) Allow the patient time to think and explore inner thoughts. E) Determine if the patient's culture requires pauses between conversation. F) Arrange for a counselor to help the patient cope with emotional issues.

C,D,E Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments.

A nurse is teaching patients of all ages in a hospital setting. Which teaching examples are appropriate for the patient's developmental level? Select all that apply. A) The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. B) The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. C) The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. D) The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. E) The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. F) The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

C,D,E Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions.

the CURE hierarchy

Critical: Emergent, life-threatening situations. Urgent: Situations in which the client could suffer harm of discomfort if there is a delay in addressing the client's needs. Routine: Routine tasks associated with client care. Extras:Tasks that are not essential to client care but promote comfort

A patient states, "I have been experiencing complications of diabetes." What question will the nurse use to elicit additional information? A) "Do you take two injections of insulin to prevent complications?" B) "Are you using diet and exercise to help regulate your blood sugar?" C) "Have you been experiencing the complications of neuropathy?" D) "Can you tell me about the complications you've experienced?"

D Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments.

A nurse enters a patient's room and finds them vomiting bright red blood. After taking vital signs, the nurse communicates the event to the health care provider using the SBAR format. Which information will the nurse include in the "A" portion of the SBAR communication? A) Admitted with peptic ulcer and bleeding disorder B) Found vomiting in bathroom C) Anti-ulcer medication recommendation D) Vital signs, oxygen saturation, bright red emesis

D The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments.

The charge nurse overhears an AP yelling loudly to a patient who is hard of hearing, while transferring them from the bed to a chair. Upon entering the room, which response by the charge nurse is most appropriate? A) "Please speak more quietly so you don't disturb the other patients." B) "Let me help you with your transfer technique." C) "When you are finished, be sure to apologize for shouting." D) "When your patient is safe and comfortable, meet me at the desk."

D The charge nurse should direct the AP to see to the patient's safety, then address any concerns privately. The nurse then can discuss appropriate use of therapeutic communication.

A nurse enters a patient's room and examines the patient's intravenous (IV) fluids and cardiac monitor. When asked, "who are you?", which response by the nurse is most appropriate? A) "I'm just the IV therapist checking your IV." B) "I've been transferred to this division and will be caring for you." C) "I'm sorry, my name is John Smith and I am your nurse." D) "I am John Smith, your nurse, and I'll be caring for you until 11 PM.

D The nurse should identify themselves, ensure the patient knows what will be happening, and the duration of their relationship.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." How will the nurse best communicate a therapeutic response? A) The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." B) The nurse places a hand on the patient's arm and states, "You feel so alone." C) The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D) The nurse holds the patient's hand and asks, "Tell me what feeling so alone is like for you?"

D The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A nurse on the rehabilitation unit is counseling a young adult athlete who sustained a traumatic below-the-knee amputation following a motorcycle accident. The patient refuses to eat or ambulate, stating, "What's the point? My life is over. I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response? A) "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." B) "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." C) "You should concentrate on other sports that you could play even with prosthesis." D) "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

D This answer communicates respect and sensitivity to the patient's needs and offers an opportunity to discuss their feelings with the nurse or another health care professional. The other answers do not allow the patient to express their feelings and receive the counseling they need.

A toddler with vomiting, diarrhea, and dehydration is being seen at an acute care center. During the admission interview, what question will the nurse ask the parents to elicit the most useful information? A) "Watching your child vomiting and in discomfort must have been scary." B) "This started yesterday, correct?" C) "Has this child has had anything to drink?" D) Could you tell me the color and approximate amount of the vomiting?

D Using a clarifying question or comment allows the nurse to gain an understanding of the parents' observations, avoiding misunderstandings that could lead to an inappropriate nursing diagnosis. A reflective question technique involves repeating what the person has said or describes the person's feelings. Assertive questions are direct, demonstrating the ability to stand up for self or others, using open and honest communication. Open-ended questions encourage free verbalization and expression of what the parents believe to be true.

Creating connections with others is a powerful tool in conflict engagement. It is recommended to use the PEARLA approach. What does this stand for?

Presence, Empathy, Acknowledgment, Reflect (or Reframe), Listen openly, and Ask questions.

Responsibilities for informed consent: Provider, Client, Nurse

Provider: obtains informed consent Client: gives informed consent Nurse: witnesses informed consent

Five rights of delegation

a) Right Task b) Right Circumstance c) Right Person d) Right Direction/Communication e) Right Supervision

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A) Closely assessing the patient before, during, and after the procedure B) Hyperoxygenating the patient before and after suctioning C) Limiting the application of suction to 20 to 30 seconds D) Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve E) Using an appropriate suction pressure (80 to 150 mm Hg) F) Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube

a, b, d, e, f. Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage.

A nurse is caring for a patient experiencing a fluid volume deficit. What should be included in the recorded intake and output for the patient? Select all that apply. A) Urine B) Carbonated beverage C) Formed stool D) Vomitus E) Chicken noodle soup F) Pressure wound irrigant

a, b, d, e. The nurse includes urine, emesis, liquid stool, drainage from wounds, and drains in the output. Intake includes IV fluids, foods, and liquid at room temperature. The liquid portion of the chicken noodle soup can be measured; however, the nurse excludes the solids. Irrigation to a pressure wound is not absorbed; rather, it drains out after cleansing the wound.

Nursing students enrolled in a leadership and management course discuss the roles of the nurse manager during post conference. What roles should the students include in the discussion? Select all that apply. A) Developing and overseeing a unit budget for staff and patient care B) Hiring, evaluating, and promoting staff growth C) Performing patient care D) Developing treatment plans to improve care and patient outcomes E) Handling escalating situations between caregivers and patients

a, b, e. Responsibilities of the nurse manager include overseeing day-to-day operations, designing and managing a budget, supervising and providing training to team members, hiring and evaluating nursing staff, handling escalating situations between patients and health care providers, and collaborating to attain optimal patient outcomes. Nurse managers' roles do not typically include performing patient care or developing treatment plans.

A chief nursing officer with a transformational leadership style is developing a plan for success to obtain Magnet status. What are the most appropriate strategies for the leader to use? Select all that apply. A) Sharing their vision of excellence in patient care and high-level education B) Encouraging nurses to incorporate evidence-based practice through hospital committees and to join nursing organizations C) Promoting compliance by reminding subordinates that they have a good salary and working conditions D) Ensuring employees are kept abreast of new developments in their department and the larger organization E) Writing the Magnet application and supporting documentation with limited input from the nursing staff F) Encouraging nurse managers and nurses to self-schedule as long as proper coverage is maintained

a, b. Transformational leaders inspire, motivate, create intellectually stimulating practice environments, and challenge themselves and others to grow personally and professionally. They demonstrate caring and vulnerability, communicating honestly and openly. They are risk takers and pay attention to process as well as outcomes. Instituting a reward program and reminding workers that they have a good salary and working conditions are examples of transactional leadership, which is based on a task-and-reward orientation. Ensuring that employees keep abreast of new developments in nursing care is a characteristic of quantum leadership. The group and leader work together to accomplish mutually set goals and outcomes with the democratic leadership style, and the laissez-faire style encourages independent activity by group members, such as setting their own schedules and work activities.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? Select all that apply. A) Making sure the oxygen is flowing into the prongs B) Maintaining oxygen saturation between 94% and 98% C) Encouraging the patient to breathe through their nose with their mouth closed D) Initiating the oxygen flow rate at 6 L/min or more E) Protecting the patient's skin from irritation by the oxygen tubing

a, c, e. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should encourage the patient to breathe through their nose with the mouth closed. The nurse should adjust the flow rate and maintain the patient's oxygen saturation as prescribed. The nurse should implement pressure injury prevention strategies; pressure from the tubing could result in medical device-related alterations in skin integrity.

A nurse who is considered a servant leader is working in an economically depressed community setting up a free mobile health clinic. Which actions best exemplify a servant leader? Select all that apply. A) Motivating coworkers to solicit funding to set up the clinic B) Setting only realistic goals that are present oriented and easily achieved C) Forming an autocratic governing body to keep the project on track D) Spending time with supporters to help them grow in their roles E) Ensuring that other's lowest priority needs are served F) Prizing leadership because of the need to serve others

a, d, f. To serve as servant leaders, nurses need to invest in those who support the organization's values, show passion, can play to their strengths, and demonstrate a positive attitude. They should develop their vision to see the future related to a current anticipated need and motivate others to follow and engage. They also need to provide ongoing opportunities for collaborations, sharing, reflection, encouragement, and celebration as well as hard work. The servant leader allows others to have a voice, to exercise control, and to practice leading themselves. The servant first makes sure that other people's highest priority needs are being served. The best test, and most difficult to administer, is: Do those served grow as people? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?

A student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance? A) Peak flow meter B) End-tidal CO2 monitor C) Chest tube D) Arterial blood gas

a. A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation (Burns & Delgado, 2019; Seckel, 2018). A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid-base status; it is invasive and not performed in the school setting.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What action will the nurse take next? A) Removing the IV from the site and start at another location B) Immediately notifying the primary care provider C) Outlining the affected area in ink and monitoring for changes D) Aspirating the catheter and attempting to flush again

a. If the peripheral venous access site leaks fluid when flushed, the nurse should remove it from the site; evaluate the need for continued access; and, if clinically necessary, restart the IV in another location. This action is a nursing intervention; the primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse is using the PIE format to document care of a patient who is diagnosed with type 2 diabetes. What information does the nurse need to complete documentation in this format? A) Patient problem list B) Narrative notes describing the patient's condition C) Overall trends in patient status D) Planned interventions and patient outcomes

a. In the PIE format, patient problems are numbered; documented in the progress notes; worked up using the Problem, Intervention, Evaluation (PIE) format; and evaluated each shift. Resolved problems are dropped following the nurse's review. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using charting by exception (CBE). Planned interventions and patient-expected outcomes are the focus of the case management model.

A nurse on the respiratory unit is interpreting ABGs for several patients. The patient with which problem will the nurse suspect may have developed respiratory alkalosis? A) Hypoxia B) Atelectasis C) Chronic respiratory illness D) Sedative overdose

a. Patients experiencing hypoxia will breathe rapidly, "blowing off" CO2. This drives the pH up reflecting alkalosis related to the respiratory system.

A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first? A) Place the patient in Fowler position. B) Encourage diaphragmatic breathing. C) Ask the patient to cough. D) Initiate oral suctioning of secretions.

a. Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.

A nurse is caring for a group of patients. The patient with which problem would the nurse identify is at high risk for fluid volume excess? A) Renal failure B) Vomiting C) Hypernatremia D) NPO for surgery

a. Patients with renal (kidney) failure are unable to excrete fluids; they typically have oliguria and fluid volume excess. The other patient scenarios typically occur in patients with fluid volume deficit.

A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse's priority nursing action at this time? A) Removing the suction catheter and elevating the head of the bed B) Notifying the primary health care provider C) Confirming the size of the oral airway is correct D) Placing the patient in the supine position

a. The nurse discontinues suctioning, elevates the head of the bed, and turns the patients to the side to prevent aspiration. Airway protection takes priority; after positioning the patient, the nurse continues to suction the airway and oropharynx. Once airway patency has been established, the nurse will notify the provider of vomiting. There is no indication the oral airway is too large. Placing the patient supine while vomiting is inappropriate, as that could promote aspiration.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline at 250 mL /hr. The patient is apprehensive and presents with a pounding headache, rapid pulse, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A) Discontinuing the infusion immediately, monitoring vital signs, and reporting findings to the primary care provider immediately B) Slowing the rate of infusion, notifying the primary care provider immediately, and monitoring vital signs C) Pinching off the catheter or securing the system to prevent entry of air, placing the patient in the Trendelenburg position, and calling for assistance D) Discontinuing the infusion immediately, applying warm compresses to the site, and restarting the IV at another site

a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. The other choices are interventions for fluid overload; air embolus; and phlebitis, respectively.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A) Slowing or stopping the infusion; monitoring vital signs, notifying the health care provider, and placing the patient in an upright position with their feet dependent B) Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider immediately, and administering antihistamine parenterally as needed C) Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider, and treating symptoms with acetaminophen D) Stopping the infusion immediately, obtaining a culture of the patient's blood, monitoring vital signs, notifying the health care provider, and administering antibiotics immediately

a. The patient is displaying signs and symptoms of circulatory overload: too much fluid volume as a result of the infusion of blood. In the other choices, the nurse is providing interventions for an allergic reaction; responding to a febrile reaction; and providing interventions for a bacterial reaction, respectively.

continuing health care

addresses long-term or chronic health care needs over a period of time Examples include hospice, end-of-life care, palliative care, adult day care

ABCDE Method of Prioritization

airway breathing circulation disability exposure

non-rebreather mask

allows higher levels of oxygen to be added to the air taken in by the patient - 80%-95% flow rates of 10-15 L - delivers highest level O2 concentration possible - perform hourly assessments of the valve and flap - make sure client uses nasal cannula during meals - use with caution for clients who have a high risk of aspiration or airway obstruction

simple face mask

an oxygen-delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose - 35-50% at flow rates of 6 (minimum) -12 L - make sure the client wears this during meals - it is more comfortable than nasal cannula - it provides humidified oxygen - face masks pose a greater risk of aspiration

A nurse restrains a client and administers an injection without their wishes. This is an example of what tort? a) assault b) battery c) false imprisonment

b Battery is intentional and wrongful physical contact with a person that involves an injury or offensive contact

A graduate nurse and preceptor are discussing protected health information (PHI) and HIPAA laws. The preceptor explains that PHI can be released without the patient's signed authorization in which situations? Select all that apply. A) News media are preparing to report on a patient who is a public figure. B) Data are needed for the tracking and notification of disease outbreaks. C) Protected health information is needed by a coroner. D) Child abuse and neglect are suspected. E) Protected health information is needed to facilitate organ donation. F) The sister of a patient with Alzheimer's disease wants to help provide care.

b, c, d, e. According to HIPAA, a health institution may share PHI without written patient authorization for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, responding to a valid subpoena, and providing information needed by coroners, medical examiners, funeral directors, and law enforcement in the case of a death from a potential crime and for facilitating organ donations. The nurse does not provide information to a news reporter without the patient's express authorization; typically, a hospital representative communicates with the media. A patient who has Alzheimer's disease will still need a release to share information; this may be given by the power of attorney.

A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient? Select all that apply. A) Avoiding turning the patient to prevent disconnections in the tubing B) Maintaining an occlusive dressing on the site C) Assessing the patient for signs of respiratory distress D) Keeping the chest drainage device at the level of the patient's thorax E) Ensuring there are no dependent loops or kinks in the tubing F) Observing for bubbles indicating air leak in the water seal chamber

b, c, e, f. The chest drainage collection device must be positioned below the tube's insertion site. Maintaining an occlusive dressing helps prevent air leak; assess for crepitus around the chest tube site indicating air leak. Avoid dependent loops or kinks in the tubing, which could impede drainage. Assess for bubbling in the water seal, maintaining the water level at the 2-cm mark. When a chest tube becomes separated from the drainage device, the nurse should submerge the tube's end in water, creating a temporary water seal and allowing air to escape until a new drainage unit can be attached.

A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately? Select all that apply. A) Tilt the patient's head forward. B) Begin ventilation using a manual resuscitation bag (Ambu bag). C) Place the mask tightly over the patient's nose and mouth. D) Pull the patient's jaw backward. E) Compress the bag twice the normal respiratory rate for the patient. F) Recommend that a sputum culture for cytology is obtained.

b, c. The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient's nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.

A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A) Avoid exercise. B) Take steps to manage or reduce anxiety. C) Eat meals 1 to 2 hours prior to breathing treatments. D) Eat a high-protein/high-calorie diet. E) Maintain a high-Fowler position when possible. F) Drink 2 to 3 pints of clear fluids daily.

b, d, e. When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercises and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.

A nurse manager is planning to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: A) The nurse devises a plan to switch to EHR. B) The nurse records the time spent on written records versus EHR. C) The nurse attains approval from management for new computers. D)The nurse analyzes all options for converting to EHR. E) The nurse installs new computers and provides an in-service for the staff. F) The nurse explores possible barriers to changing to EHR. G) The nurse follows up with the staff to check compliance with the new system. H) The nurse evaluates the effects of changing to EHR.

b, f, d, c, a, e, h, g. Planned change involves the following steps: (1) recognize symptoms that indicate a change is needed and collect data, (2) identify a problem to be solved through change, (3) determine and analyze alternative solutions, (4) select a course of action from possible solutions, (5) plan for making the change, (6) implement the change, (7) evaluate the change, and (8) stabilize the change.

A nurse in the emergency department is caring for a patient who had eaten shellfish and is now wheezing. The nurse explains to the patient that the health care provider has prescribed a bronchodilator, which will have what action? A) Helping the patient cough up thick mucus B) Opening narrowed airways and relieving wheezing C) Acting as a cough suppressant D) Blocking the effects of histamine

b. A bronchodilator opens narrowed airways which result in wheezing. An expectorant encourage cough to clear secretions. A cough suppressant reduces, treats, or stops a cough. Medications that block histamine (antihistamine) are often used for allergy but are not specific bronchodilators.

A nurse erroneously administered two tablets of acetaminophen totaling 650 mg to their patient. When reporting this to the nurse manager, the nurse states, "there are two tablets in a package labeled '325 mg. acetaminophen.' The prescription reads 'administer 325 mg of acetaminophen;' therefore, I administered what was in the package." Based on a philosophy of just culture, what should happen next? A)The nurse should be found at fault for not clarifying the order. B) The package labeling should be reviewed with the pharmacy. C) The nurse should be disciplined. D) No follow-up is needed as the medication is over the counter.

b. A just culture is committed to accountability and safety. Nurses are encouraged to disclose clinical errors and potential error situations without the fear of punitive actions, allowing others to learn from this experience. Health care workers within the organization discuss concerns and challenges related to patient care, turning them into opportunities for improvement.

A nurse manager who is working to institute the SBAR communication process for all health care providers is meeting resistance to the change. How does the manager best approach the resistance? A) Containing the anxiety in a small group and moving forward with the initiative B) Explaining the change and listing the advantages to the person and the organization C) Reprimanding those who oppose the new initiative and praising those who willingly accept the change D) Quickly introducing the change and involving staff in implementation of the change

b. Change is ubiquitous, as is resistance to change. The manager should explain the proposed change to all affected, list the advantages of the proposed change for all parties, introduce the change gradually, and involve everyone affected by the change in the design and implementation of the process. The manager should not use the reward/punishment style to overcome resistance to change.

A patient with dehydration has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? A) Explaining the mechanisms of fluid transport in cellular compartments B) Keeping the patient's preferred fluids readily available for the patient C) Emphasizing the long-term benefit of increasing fluids D) Planning to offer most daily fluids in the evening

b. Having fluids the patient prefers readily available and within reach helps promote intake. Explanation of the fluid transport mechanisms is inappropriately complex and does not address dehydration. Meeting short-term outcomes rather than long-term outcomes is the priority at this time provides further reinforcement, and additional fluids should be taken earlier in the day.

A nursing student is actively working toward strengthening their leadership skills. What action will best assist the student to meet this goal? A) Being self-reliant in solving problems B) Being self-directed and asking for assistance when needed C) Using written communication instead of face-to-face communication D) Reporting nurses who do not follow policies to the nurse manager

b. Leader behavior includes being self-directed and knowing your limitations; demonstrating a commitment to excellence; having a clear vision and strategic focus that allow movement forward toward a creative solution; showing commitment to and passion for your work; and displaying problem-solving skills, trustworthiness and integrity, respectfulness, accessibility, empathy and caring, desire to be of service, and responsibility to enhance the personal growth of all staff.

The nurses at an acute care hospital participate in a committee focused on achieving Magnet status. Which action do the nurses suggest to help achieve this goal? A) Centralizing the decision-making and scheduling process B) Promoting self-governance at the unit level C) Deterring professional autonomy to promote teamwork D) Promoting evidence-based practice over innovative nursing practice

b. Magnet hospitals use a decentralized decision-making process, self-governance at the unit level, and respect for and acknowledgment of professional autonomy. In Magnet hospitals, 14 characteristics, the Forces of Magnetism, have been recognized that identify quality patient care, excellent nursing care, and innovations in professional nursing practice.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? A) Encouraging foods and fluids with higher sodium content B) Administering oral potassium supplements as prescribed C) Cautioning the patient about eating foods high in potassium content D) Discussing calcium-losing aspects of nicotine and alcohol use

b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering (oral) potassium supplements as prescribed. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse is providing teaching for a patient who will undergo cardiac surgery and return to the intensive care unit with an endotracheal tube. What education is most important for the nurse to provide? A) "The endotracheal tube will drain out excess secretions from the surgical site." B) "This tube is used to facilitate breathing; you will not be able to speak while it is in place." C) "This is a surgically placed tube in your neck; we will suction it frequently to remove mucus." D) "Your oxygenation will be monitored frequently using pulse oximetry."

b. Patients with an endotracheal tube are unable to speak. Explaining this to the patient preoperatively, along with information that they will be closely monitored, can help decrease anxiety. The endotracheal tube is used during anesthesia or for mechanical ventilation; it is not a surgical drain. A tracheostomy, located in the neck area, is a surgically placed artificial airway. While pulse oximetry will be used to monitor oxygenation, to prevent undue anxiety, it is most important that the patient understands speech will not be possible.

A nurse carefully assesses the acid-base balance of a patient whose bicarbonate (HCO3-) level is decreased on the ABG results. This typically occurs in patients with damage to which organ? A) Kidneys B) Lungs C) Adrenal glands D) Brain

b. The kidney primarily controls the bicarbonate level and, if damaged, can affect acid-base balance. The adrenal glands secrete catecholamines and steroid hormones. The brain may regulate respiration and therefore CO2, not the bicarbonate level.

A nurse receives a call from a friend requesting information on her mother-in-law who was just admitted to the hospital. How does the nurse best respond? A) "You shouldn't be asking me to do this. I could be fined or lose my job for disclosing this information." B) "I'm sorry; per privacy laws, I can't give out patient information—even to my best friend or a family member." C) "Because of HIPAA, you could get in trouble for asking for this information unless you are authorized by the patient to receive it." D) "Why are you asking? Are you extremely worried?"

b. The nurse should immediately clarify they must adhere to HIPAA laws to protect patient privacy and confidentiality. Mentioning penalties for breaches of privacy sidesteps the need to clearly introduce or reinforce the policy. It may be appropriate to ask the friend about her concerns, only after clarifying privacy laws.

When documenting a dressing change to a residual right limb, the nurse erroneously documents that the dressing change was performed on the left leg. How will the nurse most appropriately correct the documentation? A) Use white correction fluid to cover the error and neatly write over the correction B) Draw a single line through the error, write "mistaken entry," add correct information, and date and initial C) Blacken out the error with permanent marker and rewrite the note in the next available space D) Leave the entry in place, create a correctly written entry below, and cite the charting error above

b. The nurse should not black out, use erasers or correcting fluids to correct documentation, or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry," add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry—wrong chart" and sign off. The nurse should follow similar guidelines in electronic records.

A new home health nurse and preceptor are reviewing charting for a patient with advanced lung cancer who receives Medicare benefits. When reviewing a draft of the new nurse's documentation, which statement will the preceptor correct? A) Explained to family that irregular respirations or agitation may occur when the patient is actively dying B) Patient seemed in better spirits and reported going out for ice cream with his family yesterday C) Stage 3 pressure ulcer dressing on sacral area is dry and intact; due to be changed tomorrow D) Performed medication reconciliation with focus on pain management and anticoagulation

b. To receive Medicare services, the patient must be homebound, still needs skilled nursing care, or that the patient is dying, among others. Leaving the home for ice cream may interfere with home care benefits.

A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, "Turn up the oxygen, I'm not getting enough air." Which actions would the nurse take first? A) Suction the airway. B) Assess the pulse oximetry reading. C) Obtain a peak flow meter reading. D) Assess for cyanosis of the lips.

b. Using the nursing process, the nurse first assesses the oxygen saturation via pulse oximetry before changing the oxygen flow rate. Suctioning is provided to remove respiratory secretions; the nurse would note adventitious breath sounds or phlegm with cough indicating a need for suction. A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. While cyanosis of the lips is a late sign of hypoxemia, the nurse can quickly begin to alleviate or lessen dyspnea by simply repositioning the patient.

transactional leadsership

based on a task-and-reward orientation

A nurse is performing physical assessments for patients with fluid imbalance. Which findings indicate a fluid volume excess? Select all that apply. A) Pinched and drawn facial expression B) Deep, rapid respirations C) Moist crackles heard upon auscultation D) Tachycardia E) Distended neck veins F) Sluggish skin turgor

c, d, e. Moist crackles, neck vein distention, and tachypnea typically indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit. Sluggish skin turgor is present with fluid volume deficit.

A nurse is caring for a postoperative patient who has a prescription for morphine 2 mg IV every 3 hours. Which examples documenting pain management best reflect recommended guidelines? Select all that apply. A) 6/12/25 0945 Morphine 2 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN. B) 6/12/25 0950 Morphine 2 mg administered IV. Patient appears to be comfortable. M. Patrick, RN. C) 6/12/25 1015 Administered morphine 2 mg IV at 0945, patient reporting pain as 2 on a scale of 1 to 10. M. Patrick, RN. D) 6/12/25 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN E) 6/12/25 0945 Morphine IV 2 mg will be administered to patient every 3 hours. M. Patrick, RN F) 6/12/25 0945 Patient states they do not want pain medication despite return of pain. After discussion, patient agrees to try morphine 2 mg IV. M. Patrick, RN

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner, indicating the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes, derogatory terms, and judgments such as "response to pain appears to be exaggerated" or "seems to be comfortable." Stating that medication will be given does not document care given; this prescription/intervention belongs in the plan of care.

A nurse is caring for a patient who has developed hypernatremia. For which intravenous solution would the nurse anticipate a prescription? A) 5% dextrose in 0.9% NaCl B) 0.9% NaCl (normal saline) C) 0.45% NaCl (½-strength normal saline) D) 5% dextrose in lactated Ringer's solution

c. A solution of 0.45% NaCl (½-strength normal saline) or 0.33% NaCl (⅓-strength normal saline) are hypotonic fluids used to treat hypernatremia. As there are less particles in the ½-strength saline than in the bloodstream, infusing this fluid will cause the sodium level to decrease. Normal saline (0.9% NaCl) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. Dextrose (5%) in lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

An RN on a telemetry unit is falling behind while performing assessments and administering medications. Which task can the nurse safely delegate to the AP? A) Assessing a patient who has just arrived on the unit B) Teaching a patient with newly diagnosed diabetes about foot care C) Documenting a patient's I & O in the electronic health record D) Helping a postoperative patient out of bed for the first time

c. Documenting a patient's I & O on a flow chart does not require professional judgment and can be delegated to AP. Professional nurses are responsible for the initial patient assessment, discharge planning, health education, care planning, triage, interpretation of patient data, care of invasive lines, administering parenteral medications. What they can delegate are assistance with basic care activities (bathing, grooming, ambulation, feeding) and things like taking vital signs, measuring intake and output, weighing, simple dressing changes, transfers, and postmortem care.

A health care provider has been urgently paged to another unit and asks a nurse to enter a pain medication prescription for their patient in the electronic medical record. Which response by the nurse is most appropriate? A) "Thank you for taking care of this; I'll be happy to enter a verbal order into the electronic health record. B) "Get a second nurse to listen to the order, write the order on the health care provider order sheet, and ensure both nurses sign it. C) "I'm sorry; verbal orders can only be accepted in an emergency. Please enter this quickly before leaving this unit." D)Try calling another resident for the order or wait until the next shift.

c. In most facilities, health care providers may only issue verbal orders in an emergency. The provider is present but finds it impossible, due to the situation, to write or enter the order in the electronic health record. Calling another health care provider or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a provider is available who can quickly write/enter the order.

A nurse on the IV team is making rounds to assess patients receiving IV therapy. Under which circumstance will the nurse recommend an intravenous catheter be discontinued? A) The area surrounding the catheter is bruised. B) The patient's extremity is cool to touch. C) The site is red, warm, and swollen. D) Part of the catheter (1 mm) is visible under the dressing.

c. The IV nurse will assess the IV fluids, rate, and site. A site that is red, warm, and swollen may have developed phlebitis, and the IV catheter should be removed. A bruised area surrounding the insertion site is likely associated with the initial insertion and can be monitored. A patient with a cool extremity may be chilly or hypothermic; the nurse assesses the IV site. Having 1 mm of the catheter visible from the insertion site that is covered with an occlusive, transparent dressing does not require immediate action.

A nurse is caring for a patient in the intensive care unit. How will the nurse interpret the patient's arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3-, 14 mEq/L? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis

c. The first step is to analyze the pH; low pH indicates acidosis. This, coupled with a low bicarbonate (regulated by the kidney), indicates metabolic acidosis. The pCO2 is normal, indicating the acid-base disturbance is nonrespiratory in origin. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

The nurse on an oncology unit is caring for a patient admitted for dyspnea and wheezing. What is most important for the nurse to include in the change-of-shift report to the oncoming nurse? A) Partial bath was given B) Patient received physical therapy C) CT scan revealed a mass in the right lung D) Patient did not eat lunch today

c. The nurse's shift or handoff report includes basic identifying information about the patient. The outgoing nurse includes the patient's current health status and changes during their shift, response to nursing and medical therapy, pertinent monitoring and assessment findings (e.g., lab and radiology data), pain management, changes in orders (medications, intravenous fluids, diet, and rationale), upcoming/ongoing tests and procedures, and instructions for these, such as NPO after midnight, unfilled prescriptions for the next shift to follow up on, and patient and family questions, concerns, and needs.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A) Instructing the assistant to notify the health care team B) Assessing the patient's vital signs C) Removing the tape, adjusting the depth to the ordered depth, and retaping securely D) Taking no action, as the depth will adjust automatically

c. The tube depth should be maintained at the same level unless otherwise prescribed. If the depth changes, the nurse should remove the tape or securement device, adjust the tube to the ordered depth, and reapply the tape or securement device.

A nurse is monitoring a patient with a pleural effusion after a thoracentesis removing 1,400 mL of dark yellow liquid. What is the expected outcome of this procedure? A) Tachycardia B) Hypotension C) Reduced dyspnea D) Pulse oximetry of 88%

c. Thoracentesis involves inserting a needle into the pleural space to aspirate pleural fluid, air, or both (Morton & Fontaine, 2018). A thoracentesis may be performed to obtain a specimen for diagnostic purposes, to remove fluid or air that has accumulated in the pleural cavity and is causing respiratory difficulty and discomfort, or to instill medications (Hinkle et al., 2022).

A nurse plans to suction a patient's endotracheal tube using the open suction technique. Which intervention is appropriate for this technique? A) Using a suction catheter that is the diameter of the endotracheal tube B) Maintaining the patient in the supine position C) Administering oxygen prior to suctioning D) Changing the inline suction device every 24 hours

c. To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds (AARC, 2010; Burns & Delgado, 2019; Hess et al., 2021; Pasrija & Hall, 2020). The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a "closed technique" for suction; these are changed every 24 hours.

When caring for a patient receiving hemodialysis through an arteriovenous fistula, which action is essential for the nurse to take? A) Avoiding IM injections B) Not assessing the radial pulse on the same side as the access C) Performing BP and venipuncture on the opposite extremity D) Using the distended portion of the fistula for IV medications

c. When caring for a patient with an arteriovenous fistula for dialysis, it is essential the nurse does not compress the area. Therefore, no BP or venipuncture is performed in that extremity. The patient may receive IM injections in an area of the body without the access. Taking a radial pulse in the arm with the access will not harm the fistula. The nurse does not use the fistula for any reason other than dialysis; damage to the fistula delays lifesaving dialysis.

transformational leadership

can create revolutionary change. Often described as charismatic, transformational leaders are unique in their ability to inspire and motivate others. They create intellectually stimulating practice environments and challenge themselves and others to grow personally and professionally, and to learn.

A nurse uses the ISBARR format to report the deteriorating mental status of a patient using morphine via a patient-controlled analgesia pump (PCA) for postoperative pain. Place the following nursing statements related to this call in the correct ISBARR order. A) "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." B) "Mr. Sanchez has been difficult to arouse, and his mental status has declined over the past 12 hours." C) "You want me to discontinue the PCA pump until you see him tonight at patient rounds." D) "I am Rosa Clark, an RN working on the second floor of South Street Hospital." E) "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." F) "I suggest a decrease in the dose of morphine."

d, a, e, b, f, c. The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back.

A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A) "I'll be careful not to shake the canister before using it." B) "It's important to hold the canister upside down when using it." C) "I have to remember to inhale the medication through my nose." D) "I will continue to inhale when the cold propellant is in my throat." E) "I won't inhale more than one spray with one breath." F) "I will activate the device while continuing to inhale."

d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.

A nurse is asked to act as a mentor to a new nurse. What action will the mentor expect to perform? A) Accepting payment to introduce the new nurse to their responsibilities B) Hiring the new nurse and assigning duties related to the position C) Enabling the new nurse to participate in professional organizations D) Advising and assisting the new nurse to adjust to the work environment of a busy emergency department

d. Mentorship is a relationship in which an experienced person (the mentor) advises and assists a less experienced person (protégé). This is an effective way of easing a new nurse into leadership responsibilities. An experienced nurse who is paid to introduce an employee to new responsibilities through teaching and guidance describes a preceptor, not a mentor. The nurse mentor does not hire or schedule new nurses. Nurses do not need mentors to join professional organizations.

A patient being discharged from the hospital asks to receive a copy of their medical record. What information will the nurse give the patient? A) "I'm sorry, but patients are not allowed to copy their medical records." B) "I can make a copy of your record for you right now." C) "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." D) "I'll check with the medical records department to determine how you request a copy."

d. According to HIPAA, patients have a right to view and receive a copy of their health record; update their health record; get a list of the disclosures a health care institution has made, independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

A nurse is caring for an older adult with a fluid volume deficit related to decreased thirst sensation. For which signs and symptoms of this health problem will the nurse assess? A) Dependent edema B) Crackles in the lungs C) Neck vein distention D) Weight loss

d. Assessing weight is the most sensitive indicator of fluid balance. As fluid is lost, the patient's weight will decrease. The other options are indicative of fluid excess.

A charge nurse on the step-down unit will likely use which leadership style during resuscitation efforts for a cardiac arrest? A) Democratic B) Laissez-faire C) Servant D) Autocratic

d. Autocratic leadership assumes control over the decisions and activities of the group, such as taking charge of emergencies, dictating schedules and work responsibilities, and scheduling mandatory in-service training. Polling other nurses is an example of democratic leadership, which is characterized by a sense of equality among the leader and other participants, with decisions and activities being shared. In laissez-faire leadership, the leader relinquishes power to the group and encourages independent activity by group members. Examples of laissez-faire leadership style are allowing the nurses to divide up the tasks and encouraging them to work independently.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? A) Recording intake and output B) Testing skin turgor C) Reviewing the complete blood count D) Measuring weight daily

d. Daily weight is the most reliable indicator of fluid balance. Intake and output are not always as accurate and may involve a subjective component. Testing skin turgor may not be totally accurate due to loose skin; measurement of skin turgor is subjective. The complete blood count itself does not necessarily reflect fluid balance; however, a high hematocrit can provide further support for fluid excess or deficit.

A nurse receives a prescription for an analgesic for a patient who has compound fractures of the tibia and fibula. What schedule will the nurse use to administer the medication? Electronic health record (EHR) Health care provider order sheet 8:00 AM: Hydromorphone 1 mg IV every 2 hours PRN severe pain. -S. Jones, MD A) When the patient requests it B) Every 2 hours on the even hours C) Daily, every 2 hours D) As requested, 2 hours or more after the last dose

d. PRN means "as needed." The nurse teaches the patient that the medication may be requested every 2 hours to treat pain. If pain occurs before 2 hours elapses, the nurse provides comfort measures and collaborates with the health care provider for a change in prescription.

A nurse is maintaining airway patency in an unconscious patient by providing frequent nasopharyngeal suction. When would the nurse anticipate inserting a nasopharyngeal airway (nasal trumpet)? A) Vomiting during suctioning occurs. B) Secretions appear to contain stomach contents. C) The suction catheter touches an unsterile surface. D) Epistaxis is noted with continued suctioning.

d. Repeated suctioning may injure or traumatize the nares, resulting in nosebleed (epistaxis). The nurse would recommend insertion of a nasal trumpet, which will facilitate suction while protecting the nasal mucosa from further trauma.

A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential? A) Assessing the need to premedicate with an analgesic B) Placing the patient in low Fowler position C) Inserting the obturator into the outer cannula D) Maintaining aseptic technique

d. Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. Aseptic technique is imperative to avoid introducing organisms into the lower airway. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. In the home setting, clean technique is used.

A nurse has begun administering an intravenous antibiotic via the patient's peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A) Repositioning the extremity and raise the height of the IV pole B) Applying pressure to the dressing on the IV C) Pulling the catheter out slightly and reinserting it D) Putting on gloves; removing the catheter

d. The IV fluid is infiltrating the tissue, suggested by lack of flow, swelling, and the area feeling cool to the touch. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally, the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines, and record site assessment and interventions, as well as site for new venous access. Raising the height of the IV pole will increase the pressure causing fluid to flows; however, that will promote further infiltration of fluid.

After observing conflicts between nurses about scheduling, a nurse manager compliments the nurses for achieving the monthly goal of no patient falls. What strategy for conflict resolution did the manager display? A)Collaborating B)Competing C) Compromising D) Smoothing

d. The manager who avoids conflict by complimenting the parties and avoids disagreements is using smoothing to reduce the emotion of the conflict. The original conflict is rarely resolved with this technique. Collaborating is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. Competing results is a win for one party at the expense of the other group. Compromising occurs when both parties relinquish something of equal value.

Nursing students enrolled in a leadership and management course attend clinical on a surgical unit. As they are planning their day, they note one student has a complex patient with multiple medications and the need for frequent turning, pressure injury wound care, and tube feedings. Which action by the group best reflects effective teamwork and coordination? A) Asking patients to prioritize what they want to accomplish each day B) Including a "nice to do" for every "need to do" task on the list C) "Front loading" their schedules with "must do" priorities D) Scheduling times to assist the student with the complex patient

d. The students use teamwork and collaboration to appropriately coordinate patient care; this is the best response. By asking the patient to prioritize what they want to accomplish each day, the nurse is demonstrating an effective time management technique. To manage time, the nurse should establish goals and priorities for each day, differentiating "need to do" from "nice to do" tasks; the nurse should include the patient in this process. The nurse should also establish a time line, allocating priorities to hours in the workday in to keep track of falling behind and correct the problem before the day is lost.

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A) Assisting with all bathing and hygiene B) Telling the patient to avoid speaking during hygiene C) Teaching the patient to take short shallow breaths during activity D) Taking rest periods between activities

d. To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.

A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate? A)Bronchial B) Bronchovesicular C) Vesicular D) Wheezing

d. Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.

A nurse is looking for trends in a postoperative patient's vital signs. In which part of the electronic health record will the nurse find this information? A) Admission sheet B) Admission nursing assessment C) Progress notes D) Graphic record

d. While one set of vital signs may appear on the admission nursing assessment, the best place to find sequential recordings demonstrating a pattern or trend is the graphic record. The admission sheet and flow sheet do not include ongoing vital sign documentation.

DAR (problem-oriented medical records)

data, action, response

primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. is based on a sustained partnership between client and provider. examples include office or clinic visits and scheduled school/work centered screenings (vision, hearing, obesity)

preventative health care

focuses on educating and equipping clients to reduce and control risk factors for disease. Examples include programs that promote immunizations, stress management, occupational health, and seat belt use

hyperkalemia

high postassium levels

hypernatremia

high sodium levels

what is one common causes of low calcium levels (hypocalcemia)

hypoparathyroidism, low parathyroid hormone levels

indications that clients need help maintaining airway clearance

hypoxia (restlessness, irritability, tachypnea, tachycardia, cyanosis, decreased level of consciousness, decreased SpO2 levels), adventitious breath sounds, visible secretions, absence of spontaneous cough

secondary health care

includes the diagnosis and treatment of emergency, acute illness, or injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers, or emergent care centers

restorative health care

involves intermediate follow-up care for restoring health. examples include home health care, rehab centers, and skilled nursing facilities

tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

democratic leadership (participative leadersip)

is characterized by a sense of equality among the leader and other participants. Decisions and activities are shared. Participants are encouraged to develop their skills and strengths within the group. The group and leader work together to accomplish mutually set goals and outcomes.

hypoxemia

limited amount of oxygen in the blood

hypokalemia

low patassium levels

hyponatremia

low sodium levels

List manifestations of oxygen toxicity

nonproductive cough, substernal pain, nausea, vomiting, fatigue, dyspnea, restlessness, paresthesias

hypovolemia

occurs when there is a decreased in fluid volume and electrolytes within the body due to loss of body fluids or blood AKA 'fluid volume deficit'

problem-oriented charting

organizes patient data by diagnosis or problem

wellness is a ____ state of health

positive

PIE (problem-oriented medical records)

problem, intervention, evaluation

hypoxia

reduction of oxygen at the tissue level

oxygen toxicity

results from high concentrations, long duration of )2 therapy, severity of lung disease * should be using the lowest level of O2 necessary to maintain an adequate SpO2

late manifestations of hypoxia

stupor, cyanotic skin, bradypnea, bradycardia, hypotension, cardiac dysrhythmias

SOAP (problem-oriented medical records)

subjective, objective, assessment, plan

A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse identify as tertiary care? (select all that apply) A) intensive care unit B) oncology treatment center C) burn center D) cardiac rehabilitation E) home health care

tertiary health care involves the provision of specialized and highly technical care (the care nurses deliver to intensive care units, oncology treatment centers, and burn centers). A,B,C

Laissez-Fiare Leadership

the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. This approach encourages independent activity by group members.

vibration

the use of a shaking movement during exhalation to help remove secretions

percussion

the use of cupped hands to clap rhythmically on the chest to break up secretions

what is the purpose of focus charting?

to bring the focus of care back to the patient and the patient's concerns

Nursing actions for oxygen toxicity

use lowest level of 02 needed, monitor ABGs, notify provider, decrease 02 as ox sat improves.

postural drainage

use of body positioning to assist in removal of secretions

hypovolemic shock

when the body has lost 20% (1/5) of its blood or fluid supply

modifiable vs nonmodifiable risk factors

•Modifiable risk factors are behaviors and exposures that can raise or lower a person's risk and measures that can be taken to reduce that risk. •Nonmodifiable risk factors are conditions that increase the risk of developing a disease. Nonmodifiable factors include genetics, ethnicity/race, age, and family health history.