Nurse Logic **** I dont know

What are the 3 additional priority setting frameworks fo nursing?

1. Acute over Chronic alterations in health 2. Urgent over non urgent needs 3. Unstable over stable patients

What is a normal peak expiratory flow rate?

80-100%

When the nurse first begins to open a sterile catheter kit, which direction should it be opened?

Away from the body

What is a therapeutic level for Digoxin?

Therapeutic levels of digoxin are 0.8-2.0 ng/mL. The toxic level is >2.4 ng/mL

Describe orthopneic position and when it is used

also known as tripod position. Patient sits at the side of the bed with head resting on an over-bed table on top of several pillows. This position is used for patients with breathing difficulties.

When is a postoperative abdominal patient at greatest risk for wound dehiscence or evisceration? What can cause this to happen?

health. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first.

True or False: yellow discharge around the penis 2 days post circumcision is normal

yes, will persist for 2-3 days

What are the Seven Priority Setting Frameworks of Nursing?

1. Maslow's Hierarchy of Needs 2. Nursing Process 3. ABC's 4. Safety and Risk Reduction 5. Least Restrictive/Least Invasive 6. Survival Potential 7. Additional Frameworks

Explain what it means for a nurse to function under the role of an advocate for a patient

A nurse advocate acts as a liaison between clients and providers in order to improve or maintain the quality of care that clients receive.

A nurse in a long-term care facility is assisting w/ an educational program regarding common sites of HCA infections for a group of newly hired AP's. Which of the following sites should be included in the teaching? (SATA) A. Urinary tract B. Surgical wound C. Musculoskeletal system D. Respiratory tract E. Blood stream

A, B, D, E

A nurse reinforcing d/c teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A. Place the infant in a supine position when sleeping B. Place the infant on a firm mattress when sleeping C. Avoid covering the infant with loose bedding while sleeping D. Avoid leading stuffed animals in the crib with the sleeping infant.

A. Evidence-based practice and current recommendations of the American Academy of Pediatrics include positioning the infant supine while sleeping. This intervention has had the greatest impact on reducing the occurrence of SIDS. Using the safety and risk reduction priority setting framework and nursing knowledge, this is the priority information to include in the discharge teaching.

A nurse is caring for a client who has narcissistic personality disorder. Which of the following is a manifestation of the disorder? A. Grandiose sense of self importance B. Reckless disregard for safety of others C. Unstable interpersonal relationships D. Lack of empathy

A. Rationale: Narcissistic personality disorder is characterized by a grandiose sense of self importance, preoccupation with fantasies of success, power and beauty, requires excessive admiration, has a sense of entitlement, lacks empathy, and displays arrogant behaviors.

A nurse is caring for a client who is diagnosed w/ active pulmonary TB and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? A. Loss of color discrimination B. Nausea and Vomiting C. Red-orange discoloration to body fluids D. Edema of feed and hands

A. Rational: Ethambutol and isoniazid are both antitubercular medications. The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops.

A nurse is caring for a client who is admitted w/ acute alcohol withdrawal. Which of the following findings should the nurse report to the provider? A. Tachycardia B. Vomiting C. Hypotension D. Dilated pupils

A. Rationale: Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.

A nurse is caring for a client who has antisocial personality disorder. Which of the following is a manifestation of the disorder? SATA A. Grandiose sense of self importance B. Reckless disregard for safety of others C. Unstable interpersonal relationships D. Lack of empathy E. Unstable mood

B & D Rationale: Antisocial personality disorder is characterized by reckless disregard for self and others. Clients who have antisocial personality disorder also display impulsivity, deceitfulness, consistent irresponsibility, and lack of remorse.

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching? A. Lentils B. Soybeans C. Broccoli D. Oatmeal

B. Rationale: Food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance. Soybeans are a source of complete protein and should be included in the teaching.

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated w/ this diagnosis? A. Increased appetite B. Elevated temperature C. Bradycardia D. Drowsiness

B. Rationale: pt with acute alcohol delirium will experience an elevated temperature, tachycardia, insomnia and anorexia

A nurse is reinforcing teaching w/ a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A. "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B. "I can have 1 to 2 alcoholic beverages each week." C. "I will need to stop taking Xanax two weeks before I can begin taking this medication." D. "I can have 6 to 8 ounces of grapefruit juice each day."

B. Rationale: Buspirone is an anxiolytic medication used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching.

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy? A. 0.25 mEq/L B. 0.75 mEq/L C. 1.5 mEq/L D. 2.25 mEq/L

B. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy.

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (celestone). Because of the administration of betamethasone to the patients mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal Retractions C. Hypoglycemia D. Hypothermia

C. Rationale: Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? A. 10-15lbs B. 15-20lbs C. 20-30lbs D. 25-35lbs

D.

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? A. Spongy gums that are receding B. Fissures at eyelid corners C. Easily plucked hair D. Deep reddish-colored tongue

D.

A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A. Administer an anti-anxiety medication. B. Take the client to a place of seclusion. C. Obtain an order for soft wrist restraints. D. Engage the client in physical activity.

D. Gross motor activities can reduce tension and lower anxiety levels. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than others and should be the first action of the nurse.

A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? A. Cyanosis B. Jaundice C. Erythema D. Pallor

D. Pallor

When setting up a med calculation problem what is the forumla?

Desired x Quantity / Have

The nurse in a rehab facility is caring for a patient who has just had a CVA. The nurse review's the client's chart and finds the following information: C/O of insomnia, dry mouth, ST, HA. T: 99.8 RR: 20 HR: 90 BP: 144/ 94mm Based on this information which of the above findings should the nurse report to the provider immediately and why?

Temperature 37.6° C (99.8° F). Rationale: Sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine. Using the urgent versus nonurgent priority setting framework, this is the priority finding and should be reported immediately to the provider.

A nurse is reinforcing teaching to parents of a child who is admitted w/ rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? A. "My child will need to be followed medically for at least 5 years." B. "My child can resume moderate activity after his fever subsides." C. "This illness will not recur because my child has now had it." D. "In a few weeks or months my child could experience sudden, involuntary movements."

C. Rationale: It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed. This statement by the parent is not appropriate and indicates a need for further teaching.

A nurse is caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder? A. Grandiose sense of self importance B. Reckless disregard for safety of others C. Unstable interpersonal relationships D. Lack of empathy

C. Rationale: Unstable interpersonal relationships is correct. Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions.

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A. "It is necessary to have written consent for invasive procedures." B. "Implied consent is appropriate for some aspects of nursing care." C. "It is the responsibility of the provider to obtain express consent." D. "Informed consent should be obtained separately for each surgical procedure."

C. Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.

A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? A. Mammogram every year to detect breast cancer B. Colonoscopy every 10 years to detect colon cancer C. Dermatologist evaluation every 3 years to detect skin cancer D. Complete eye examination every year to detect eye disorders

C. Rationale: A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.

A nurse is reinforcing teaching about transdermal nitro to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? A. "I should leave the patch on for 16 to 20 hours each day." B. "I will apply a new patch in the same location each day." C. "The patch should be effective within an hour of being applied." D. "The medication is not absorbed as well when placed on the abdomen."

C. Rationale: This statement by the client is true and indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

A nurse is caring for a school-age child who is newly diagnosed w/ type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A. Provide a toy doctor's kit to play with. B. Keep all syringes and needles out of sight until needed. C. Use an approach that is firm but direct. D. Allow the child to manipulate the medical equipment.

D. Rationale: Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

A nurse is reinforcing teaching methods to decrease nausea for a pt who is receiving chemo. Which of the following statements by the client indicates a need for further teaching? A. "I should eat frequently." B. "I should avoid eating 1 to 2 hours prior to my treatment." C. "I should eat foods served cold." D. "I should eat low carbohydrate foods."

D. Rationale: Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet. This is not an appropriate statement by the client and indicates a need for further teaching.

A nurse is caring for a client who is prescribed lithium. Which of the following clinical findings should be immediately reported to the provider? A. Fine hand tremors B. Mild thirst C. Weight gain D. Slurred speech

D. Rationale: Slurred speech is an early clinical finding associated with lithium toxicity and can precipitate the onset of seizures or coma. Using the safety and risk reduction priority setting framework, this finding jeopardizes the immediate physiological safety of the client and should be reported to the provider immediately.

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicate the client could be experiencing an anastomotic leak? A. Lethargy B. Neuralgia C. Bradycardia D. Oliguria

D. Rationale: When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.