NURA 1110 Final
Assessment includes:
Chief Complaint History of Present Illness (HPI) Medical History Current Medications Allergies Surgical History Family History Social History Review of Systems (ROS) Physical Assessment
Why Should I do a Nursing Care Plan?
Provides direction for individualized care Continuity of care Documentation Guide for staff assignments Guide for reimbursement
Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?
"Always provide close supervision for young children when they are in or around pools and bathtubs."
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?
"Any information that can identify a person is considered a breach of client privacy."
During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client?
"Are you taking any B-complex vitamins?"
A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?
"Can you tell me about why you've made this decision?"
A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse?
"I use cotton-tipped applicators daily to remove cerumen."
The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?
"Is your child breathing at this time?"
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.
"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin."
A client with a new diagnosis of asthma has been prescribed a corticosteroid by metered-dose inhaler (MDI). What teaching point should the nurse include in health education?
"Rinse your mouth with water after each dose of your medication."
The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?
"Sometimes a person returns to a previous stage."
When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?
"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."
actual nursing diagnosis
- nursing diagnosis is currently present
what is the normal range for creatinine?
0.5-1.2
what is the normal range for BUN?
10-20 mg/dL
normal respiratory rate for adult
12-20
what is the normal range of the pulse for infants?
120-160
what is normal respiratory rate for a child?
20-30
how often do you change the tube feeding bag?
24 hours
before each enteral feeding, check to make sure the GRV is less than:
250 mL
normal range of WBCS
5,000-10,000
Which statement is true regarding addressing a priority problem?
A priority problem requires a nursing intervention before another problem is addressed.
A 3 problem nursing diagnosis includes:
Actual diagnosis, Related to, As evidenced by (AEB).
"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?
Actual nursing diagnosis
Which authoritative statements guide current professional nursing practice?
American Nurses Association Standards of Nursing Practice
What is review of systems?
An overall assessment of major body functions
During S2 you hear what valves open or close and what does it mark?
Aortic and Pulmonic valves close, beginning of diastole
An ultrasonic Doppler is used for:
Auscultating a pulse that is difficult to palpate
What are some of the lab tests that assess kidney function?
BUN, Cr, GFR
this is a period of breathing followed by periods of apnea. Usually indicates impending death
Cheyne-Stokes
The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?
Clamp the tube for a brief period and resume at a slower rate.
Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply.
Collecting additional client data Modifying the client plan of care
shift assessment
Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time.
The nurse is caring for a client who has had a cerebrovascular accident. Prior to administering oral medications, what is the nurse's appropriate action?
Consult with a speech therapist for dysphagia.
The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?
Contact a podiatrist to care for toenails.
ANA STANDARDS OF NURSING PRACTICE:standard 5 a
Coordination of Care: The registered nurse coordinates care delivery.
Three part nursing diagnosis
Data Analysis Problem Identification Formulation of the Nursing Diagnosis
this is the Partial or total separation of wound layers:
Dehiscence
A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?
Discuss possible alternatives to a blood transfusion with the physician.
A nurse educator is reviewing information related to medication administration documentation with a group of graduate nurses. Which guideline for documenting will the nurse discuss with the group?
Document administration of the medication immediately after administering the drug.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?
Does this task fall within the scope of a UAP?
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?
Dry the cleaned areas and apply an emollient as indicated.
A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?
Emptying a client's ileostomy appliance
The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?
Ensuring that the endotracheal tube is secure
ANA STANDARDS OF NURSING PRACTICE:standard 6
Evaluation: The registered nurse evaluates progress toward attainment of goals and outcomes.
A nurse is planning care for an adult client with severe cognitive impairments and a new diagnosis of lung cancer. What nursing action is most appropriate when establishing the priorities of care?
Include the client and his power of attorney in the discussion.
The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?
Initiate use of a bed alarm.
What is ADPIE (definition and the acronym)
It is the process for basic nursing care. Assess, diagnose, plan, implement and evaluate
A nurse documents the following assessment for an infant: temperature 98.9°F (37.2°C), pulse 90 beats/min, respirations 35 breaths/min, and blood pressure 85/37 mm Hg. What is the next appropriate action of the nurse based on these assessments?
No action is needed; these are normal assessments.
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?
Notify the physician for additional orders.
ANA STANDARDS OF NURSING PRACTICE: Standard 3
Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
this type of wound is Shallow, Loss of epidermis/ possible partial loss of Dermis, Heals by regeneration, Surgical wound abrasions, Inflammation response within 1st 24 hours, Reestablishes epidermal layers to normal tissue
Partial thickness wound repair
The physiologic and biochemical effects of a drug on the body defines:
Pharmacodynamics
A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?
Physical changes
ANA STANDARDS OF NURSING PRACTICE: Standard 4
Planning: The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes.
The nurse is preparing to administer a client's ordered tube feeding and the client aspirates gastric contents. Testing of the pH yields a result of 5.3. What is the nurse's most appropriate action?
Proceed with the feeding as ordered.
A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?
Reassess the client to determine the effectiveness of the interventions.
The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?
Refrain from using extension cords.
what is RACE?
Rescue, Alarm, Contain, Extinguish (rescue pt first)
Which nursing action promotes safety in preparation of medication?
Return medications with obscured labels to the pharmacy. Note the expiration dates on liquid medications. Prepare medications in well-lit conditions.
Which actions should the nurse take before making an entry in a client's record? Select all that apply.
Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment?
Safety
comprehensive assessment
Similar to admit assessment. Results in baseline data that enable the nurse to: Make a judgment about an individual's health status, ability to manage his or her own need for self-care and need for nursing care.
The nurse is administering the first dose of an intravenous infusion of an antibiotic. What action would the nurse take next?
Stay with the client during the first 15 minutes of infusion.
A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action?
Stop the sitz bath, call for help, and help the client to the toilet to sit down.
The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?
The client is covered with a couple of thick blankets.
A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions?
The client should avoid wearing tight clothes or belts near the site.
A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?
The client states, "I am sure the doctors have misdiagnosed me."
Eviceration
The displacement of organs outside of the body.
A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?
The first faint, but clear, sound appears.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?
The nurse has omitted the time frame.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
ANA STANDARDS OF NURSING PRACTICE: Standard 2: Diagnosis
The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.
ANA STANDARDS OF NURSING PRACTICE: Standard 1. Assessment:
The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation.
time-lapsed assessment
The time-lapsed assessment is scheduled to compare a patient's current status to the baseline data obtained earlier.
inital assessment
This would be an admit assessment. It is a comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs.
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include?
Tighten the internal muscles used to prevent or interrupt urination.
A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?
Time-lapse assessment is used
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?
Translators may need additional explanations of medical terms.
During S1 you hear what valves open or close and what does it mark?
Tricuspid and Mitral valves close, beginning of systole
Which traits of the nurse are most important for an assessment to be successful?
Trustworthy and confident
what type of syringe should be used to admin insulin?
Units (insulin)
what is the antidote to warfarin?
Vitamin K (aquamephyton)
Which set of instructions the nurse should give to a client who is going home with eye drops?
Wait for 5 minutes between instillation of eye drops. Apply the drops along the lower lid margin of the eye. Keep the application tip of the medication container sterile.
When used in a nursing diagnosis, the descriptor "impaired" has which meaning?
Weakened or damaged
A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask?
What are your expectations about bathing at this time?"
emergency assessment
When a physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life-threatening problems.
In which situation is an alcohol-based rub an inappropriate option for hand hygiene?
When the nurse's hands are visibly soiled
The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:
a cognitive outcome.
Surgical asepsis is defined as:
absence of all microorganisms.
this is the term for without fever:
afebrile
A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?
aggressive management of symptoms
The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?
alongside the bed at the same height
what must be checked before admin digoxin?
apical pulse
First aid for wounds includes:
apply pressure, clean the wound, Apply a dressing, Immobilize
what are some things to assess for prior to insertions of an NGT?
assess for bowel sounds and gag reflex, least occluded nares,
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding?
avulsion
What is Kübler-Ross's third stage of grief?
bargaining
what must be checked before admin antihypertensive?
blood pressure
A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?
child-proofing the house
what must be checked After application of restraints?
circulation, pulse, color, warmth, Make sure you are able to put 2 fingers under restraint
Risk for nursing diagnosis
client is at risk for developing this condition/injury
focuses assessment
conducted to assess a specific problem. Ex: abdominal pain, nurse asks about bladder and bowel habits. what when did symptoms start , what makes it worst?
signs of dysphagia
cough, change in voice tone or quality, delayed swallowing, incomplete oral clearance, pocketing of food, regurgitation
The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change?
decrease in flexibility
What are the stages of grief?
denial, anger, bargaining, depression, acceptance
what is the pressure exerted against the arterial walls when the ventricles relax?
diastolic
The nurse is considering the needs of the postoperative client in his home setting. What is the nurse performing?
discharge planning
What should be done if you cannot reach the prescriber for clarification of a med order?
document all attempts and notify house supervisor
this is Black or brown necrotic tissue dead tissue, May be loose or hard tissue, Needs to be removed so wound can heal,
eschar
Condition with fever
febrile
what provides the bulk of fecal material?
fiber
Don't know how many times is each ROM exercise performed?
five
When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)?
fold soiled side to the inside and roll with inner surface exposed
What is a nursing care plan?
is a written document (either electronic or paper-based) that is used and altered constantly throughout the day.
As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise?
isometric
what foods are ok on a clear liquid diet?
jello, broth, coffee, no creams
this is a deep, irregular, and rapid rate of breathing
kussmals
what position should a pt be in when admin a rectal medication?
lateral left or sim's
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
reporting
what breath sounds can be cleared with coughing?
rhonchi
what heart sounds are heard the the tricuspid and mitral valve?
s1
what heart sounds are heard at the aortic and pulmonic valve?
s2
8 rights of medication administration
time, patient, medicine, dose, route, documentation, effect, education
An order was made for a client who is cognitively impaired to have a nitroglycerin transdermal patch. On which area of the body is the nurse expected to place the patch?
upper back
what site is used for infants, toddlers, and adults receiving immunizations?
vastus lateralis
what must be done after insertion of an enteral tube?
verify with x-ray
what categories of vitamins should a person consume for nutritional benefit of wound healing and pressure ulcer risk reduction?
vitamin a, c, zinc, copper, calories, protein, iron
An older adult client has been prescribed a transdermal patch. Which client statement demonstrates the need for further teaching by the nurse?
"This medication is likely to work slower on me than on a younger person."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
"To prevent the legs from rotating outward."
how often must a restrain order be renewed?
24 hours
A nurse is caring for an adult client who ate a chicken breast and drank a glass of water. There are 60 grams of protein in the chicken breast. Calculate the energy intake, in kilocalories, for this food. Record your answer using a whole number.
240
what is the minimum urine output?
30 mL/hr
this is the range of the Braden scale
6 (highest risk)-23 (lowest risk)
what is the normal pulse range for adults?
60-100 bpm
what is the normal range of the pulse for adolescents?
60-90
what is the normal range of the pulse for preschoolers (age 2-5)?
80-110
The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?
Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.
Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?
Focus assessment
ANA STANDARDS OF NURSING PRACTICE: standard 5b
Health Teaching and Health Promotion: The registered nurse employs strategies to promote health and a safe environment.
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery
Types of drainage devices:
Hemovac, Jackson-Pratt, Penrose, Wound vac assisted care
what are the side effects of corticosteroids?
Hyperglycemia (elevated blood sugar), Adrenal gland suppression w/ long-term use, Alterations in sleep cycle, Thinning of skin/easy bruising, Osteoporosis, Immune suppression
Which principle should guide the nurse's collection of a fecal occult blood test?
If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period.
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?
Impaired Physical Mobility related to pain
ANA STANDARDS OF NURSING PRACTICE: standard 5
Implementation: The registered nurse implements the identified plan.
A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation?
Lower the solution container and check the temperature and flow rate.
Which is an example of a nurse-initiated intervention?
Teaching a client how to splint an abdominal incision when coughing and deep breathing.
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown
The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?
a critical care client
what are the signs of a stage 4 ulcer?
full thickness tissue loss, exposed bone, tendon, muscle
A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?
functional incontinence
this is Red moist tissue which is composed of new blood vessels indicated progression toward healing
granulation tissue
what are some reactions of furosemide and what is it indicated for?
hearing loss, dehydration, hypokalemia, CHF, Edema, hypertension
What does etiology identify?
identifies factors causing undesirable response and preventing desired change.
pt fall, needle stick, med errors should be recorded in an:
incident report
these Situations use surgical asepsis:
intentional perforation of skin, IV or catheters, surgical incision or burn, Insertion of catheters, In operating rooms, labor and delivery
Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply.
lentils onions cabbage
what is furosemide and what is the trade name?
loop diuretic, lasix
this type of dressing security is commonly used for large drainage helps save the skin
montgomery ties
What is the antidote to acetemenophine?
mucomyst/ acetylecystine
What is the antidote to narcotic overdose?
narcan/ naloxone
what are the signs of a stage 2 pressure ulcer?
partial thickness, shallow open ulcer without slough, blister
The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?
placing the client in good alignment with joints slightly flexed
this type of wound is closed wound is sutured or stapled, Heals quickly with minimal scaring:
primary intention
What is the antidote to heparin?
protamine sulfate
The nurse is caring for a client after a facial tumor was surgically removed. The primary care provider ordered a regular diet. Which diet modification would be the best choice for the client?
pureed
this is Clear watery plasma drainage:
serous
this type of bath is A soak with warm water and then some cool for patients that had rectal surgery:
sitz bath
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity
what is the S1 sound "lub"?
systole
what is normal respiratory rate for an infant?
30-60
The nurse is teaching a new mother who had decided to breastfeed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding?
iron
what pH indicates that the tube is placed in the stomach?
less than 4
A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:
niacin
what are the signs of stage 1 pressure ulcer?
non-blanchable redness, redness, warmth, edema, hardness, pain
who should restrain a child during an injection? who should comfort?
nurse, parent
Temperature 98.8, Heart rate 65 is what type of data?
objective
this drainage is Thick yellow green brown tan
purulent
Which nursing techniques should the nurse use to assist a client who is having difficulty using the metered-dose inhaler correctly? Select all that apply.
re-demonstrating the correct use of a metered-dose inhaler observing the client's technique when using the metered-dose inhaler at least four times monitoring the client's saturated oxygen with a pulse oximeter before and after the use of the metered-dose inhaler
when planning pt goals, the goals must be:
realistic, pt involvement, pt centered, measurable, time frame
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
rectum
this type of Wound's edges not approximated pressure ulcers surgical wounds with tissue loss granulation tissue formation wound contraction
secondary intention
Braden scale categories:
sensory perception, moisture, activity, mobility, nutrition, friction and shear
this is Pale pink watery mixture of clear and red fluid
serosanguineous
this is Soft yellow or white tissue tissue stringy substance attached to wound needs to be removed so wound can heal
slough tissue
what stage of pressure ulcers is non-blanchable redness of intact skin, Discoloration of the skin warmth edema, hardness, or pain?
stage 1
what state of pressure ulcer is full thickness skin loss (fat visible), Subcutaneous fat may be visible but bone tendon or muscle is not exposed, May include undermining and tunneling
stage 3
what state of pressure ulcer is full thickness tissue loss (muscle/bone), Has exposed bone tendon or muscle slough or eschar may be present often includes undermining and tunneling
stage 4
if a pt questions you regarding the meds ,what must you do?
stop, double check, possibly verify with prescriber
if a pt has unilateral weakness, where should you place a pill and what should you instruct the pt to do?
stronger side of mouth, turn head towards weaker side
"I am tired all of the time" is an example of what kind of data?
subjective