rationales

protective environment for allogenic stem cell transplant facts

- positive pressure airflow -they are at greater risk for infection -at least 12 air exchanges per hour

facts for thigh length sequential compression sleeves

-ankle pressure should be between 35-55mmhg - the nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure - the pt should. be in a dorsal or semifowlers position

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. -place a name tag on the body -wash the clients body -remove tubes and indwelling lines -ask the clients fam members if they would like to view the body -obtain the pronouncement of death from the provider

-obtain the pronouncement of death from the provider -remove tubes and indwelling lines -wash the clients body -ask the clients fam members if they would like to view the body -place a name tag on the body

Creatinine range

0.5-1.1 mg/dL

BUN range

10-20 mg/dL

a nurse is preparing to administer 0.9 sodium chloride 750ml IV. to infuse over 7hr. the nurse should set the infusion pump to deliver how many ml/hr?

107

Sodium range

135-145 mEq/L

potasium range

3.5-5

the prescription reads 25000 units of heparin in 0.9 perfect sod chloride 250ml to infuse at 800ml/hr. at what rate should the pump flow?

8

a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of reg physical activity. which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bicycle c. performing isometric exercises d. engaging in high impact aerobics

a. walking briskly

a nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctiva d. visual fields e. visual acuity

b,d,e

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply a gait belt to the client

c. assess the client for orthostatic hypotension

a nurse is reviewing a client's medication that reads, "digoxin 0.25 by mouth every day" which of the following components of prescription should the nurse verify w the provider a. med name b. route of administration c. med dose d. frequency of administration

c. med dose

How do you draw up insulin?

cloudy, clear, clear, cloudy

a nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control the nurse should inform the client that this condition is a contraindication for which of the following therapies a. biofeedback b. aloe c. feverfew d. acupuncture

d. acupuncture

contact precautions equipment

exam gloves and isolation gown

protective environment precautions

for someone who has a compromised. immune system -positive airflow -HEPA filter -gloves, gown, respirator mask -no flowers/plants

what type of dressing for stage 4 or unstageable? wound

gauze - promotes healing by causing debridement & allowing granulation of the wound bed

group discussion pt teaching

meetings promote cognitive learning

questions-answer meetings for pts

meetings promote cognitive learning

TB precautions and care

n95 wear gloves w oral care neg air pressure room use hand sanitizer

practice sessions for teaching pts

practice sessions require psychomotor skills when learning

contact precautions

practices used to prevent spread of disease by direct or indirect contact

Airborne precautions protective equip

private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB

Ginkgo biloba

taken to improve memory and reduce stress

feverfew

taken to promote wound healing

What is the sick role?

- expectations of others and society regarding how one should behave when sick [e.g., caring for self and continuing to provide childcare to grandchildren]

cane facts

- the top of the cane should be even with the greater trochanter - to maintain balance move the cane forward 15-30 cm at a time -client should move her weaker leg forward with the can - the client should hold the cane on the stronger side

facts for peripheral its on older clients

-10/30 degree angle - place the clients arm win a dependent position -nurse should clip excess hair not shave - do not use fragile veins like the ones in the hand

a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take? a. use a resuscitate bag w 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170mmhg

b. select a suction catheter that is half the size of the lumen

a nurse is admitting who has an abdominal wound with a large amount of purulent drainage. which of the following types of transmission precautions should the nurse initiate? a. protective environment b. airborne precautions c. droplet precautions d. contact precautions

d. contact precautions

a charge nurse is discussing the responsibility of nurses caring for clients who have c diff infection? which of the following information should the nurse include in the teaching? a. assign the client to a room w a neg airflow system b. use alcohol based hand sanitizer when leaving the room c. clean contaminated surfaces with phenol solution d. have fam members wear a gown and gloves when visiting

d. have fam members wear a gown and gloves when visiting

What is role conflict?

difficulty in satisfying the requirements or expectations of multiple roles

Droplet precautions

Must be followed for a patient known or suspected to be infected with pathogens transmitted by large-particle droplets expelled during coughing, sneezing, talking, or laughing.

a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family? a. check the cord routinely for frays or tearing b. keep the unit 4ft from gas stove c. consider purchasing a generator fro power backup d. observe for signs of hypoxia e. sleeve synthetic clothing and bedding

a, c, d

a nurse is caring for a group clients on a medical surgery unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmingly b. a client who has a prescription for a ng tube refuses it, and the nurse complies with the client's wishes c. a client who has a dnr order has a cardiac arrest, and the nurse does not perform CPR despite requests from the clients family d. a client who is about to undergo a painful procedure receives pain medication30 min before the procedure that the nurse previously promised

a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmingly

a nurse is preparing to administer enoxaparin subs to a client which of the following actions should the nurse take? a. administer the needle at 45 deg angle b. massage the injection site c. put in nondominant arm d. pull the clients skin down prior to admin

a. administer the needle at 45 deg angle

a nurse is preparing an education program for staff about advocacy. which of the following should the nurse include? a. advocacy ensures the client's safety, health, and rights b. advocacy ensures that nurses ate able to explain their own actions c. advocacy ensures that nurses follow through on their promises to clients d. advocacy ensures fairness in client care delivery and use of resources

a. advocacy ensures the client's safety, health, and rights

a nurse is preparing to delegate client care tasks to an assistive personnel. which of the following can be delegated? a. ambulating a client who is post op b. inserting an indwelling urinary catheter into a pt c. demonstrating the use of an incentive spirometer d. confirming that a client's pain has decreased after receiving analgesic

a. ambulating a client who is post op

a nurses administering an opioid drug and only needs 1ml of a 2ml vial which of the following actions should nurse do next? a. ask another nurse to witness the med waste b. notify pharmacy when wasting the med c. lock the remaining med in controlled substances container d. dispose of the vial with the remaining med in a sharps container

a. ask another nurse to witness the med waste

a nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first a. check the client for injuries b. move hazardous objects from the client c. notify the provider d. ask the client to describe how she felt prior to the fall

a. check the client for injuries

a nurse is admitting a client who is having an exacerbation of heart failure. In planning the client's care, when should the nurse initiate discharge planning? a. during the admin process b. as soon as the clients condition is stable c. during the initial team conference d. after consulting with the clients fam

a. during the admin process

a nurse is caring for a client who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? a. examine personal values about the issue b.tell the parents that it is a necessary procedure c. inform the parents that the staff does not require their consent d. contact a spiritual support person to explain the importance of the procedure

a. examine personal values about the issue

a nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints. which the following actions should the nurse take? a. pad the clients wrists before applying b. evaluate the clients circulation every 8 hours after applying c. remove the restraint every 4 hours to evaluate the clients status d. secure the restraint to the bed rail

a. pad the clients wrists before applying

a charge nurse is observing a newly licensed nurse prepare a strike field for a dressing. which of the following actions by the newly licensed requires intervention by the charge nurse? a. the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field b. the newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring c. the newly licensed nurse places sterile objects 2.5 cm 1 inch within the border of the field d. the sterile field is positioned at the level of the newly licensed nurse's waist

a. the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

a nurse is caring for a patient who has a terminal illness and is approaching death. the client is short of breath and has noisy respirations from secretions in their airway. which of the following actions should the nurse take? a. turn pt every 2 hrs b. administer an antiemetic every 6hr c. hold oral care d. increase the room temp

a. turn pt every 2 hrs it breaks up the secretions

a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching? a. use the correct name of the medication magnesium sulfate b. delete the space between the numerical dose and the unit of measure c. write the letter U when noting. the dosage of insulin d. use the abbreviation sc when indicating an injection

a. use the correct name of the medication magnesium sulfate

a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client? a. use. a bed exit alarm system b. raise 4 rails while the client is in bed c. use one soft arm restraint d. dim the lights in the clients room

a. use. a bed exit alarm system

a nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. what could I have done to deserve this illness b. I blame medical science for not curing me c. where is my daughter at a time like this d. will I ever begin to feel in charge of my life again

a. what could I have done to deserve this illness

what type of dressing for stage 3 or 4 ? wound

aliginate- promotes healing to absorb drainage, forms a soft gel when it comes to contact with drainage

patient is receiving blood and reports feeling itchy and anxious. his face is flushed and has hives. the client has manifestations of ________( allergic rxn, febrile rxn, fluid overload). as evidenced by __________ (. itching, temperature, oxygen saturation)

allergic reaction AEB itching

What is biofeedback?

alternative therapy to assist clients w stroke recovery, smoking cessation, headaches, and many other disorders

a nurse is providing discharge instructions to a client who will b using a walker. which of the following client statements indicates an understanding of the teaching? a. I can place an extension cord across my living room floor b. I will hire someone to trim the tree that hangs low over the stairs of the front porch c. I will place my alarm clock on my bedroom dresser across the room d. I will replace the old throw rug in my kitchen with a new one

b. I will hire someone to trim the tree that hangs low over the stairs of the front porch

a community health nurse is checking bp at a community health screening who is the biggest risk for hypertension a. a 52 year old b. a client who smoke a pack a day c. client who walks 30min a day d. one glass a wine 3x a week

b. a client who smoke a pack a day

a nurse is performing a skin assessment for a client who expresses concern about skin cancer. which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. the presence of papule b. a mole with an asymmetrical appearance c. new appearance of petechiae d. a lesion with uniform pigmentation

b. a mole with an asymmetrical appearance

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temp d. diagnostic test results

b. breath sounds

a nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. which of the following actions is the nurse's priority? a. request that a resp therapist discuss the technique for incentive spirometer with the client b. determine the reasons why the client is refusing to use the IS c. document the client's refusal to participate in health restorative activities d. administer a pain medication to the client

b. determine the reasons why the client is refusing to use the IS

a nurse his caring for a client who has pharyngeal diphtheria. which of the following types of transmission precautions should the nurse initiate? a. contact b. droplet c. airborne d. protective

b. droplet

a nurse is assessing four adult clients. which of the following physical assessment techniques should the nurse use? a. use the face, legs, activity, cry, and consolability (flack) pain rating scale for a. client who is experiencing pain b. ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm c. obtain an apical heart rate by auscultating at the third intercostal space left on the sternum d. palpate the client's abdomen before auscultating bowel sounds

b. ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm

a nurse is caring for a client who has a terminal illness and is at the end of life. the nurse should recognize that which of the following statements by the client's partner indicates effective coping? a. I am not worried bc I still have hope he will be ok b. im relying on support from my fam rn c. we can plan the fam reunion when he recovers d. we don't see reason to start planning a funeral

b. im relying on support from my fam rn

a nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client? a. make sure the clients room has at least 6 air exchanges an hour b. make sure the client wears a mask when outside her room if there is construction c. place the client in a private room w/ neg pressure flow d. wear an n95 when giving pt care

b. make sure the client wears a mask when outside her room if there is construction

a nurse is planning to insert a peripheral iv catheter for an older client. which of the following ac tons should the nurse plan to take? a. insert the Cath at a 45 deg angle b. place the client's arm in a dependent position c. shave the excess hair from the insertion site d. initiate IV therapy in the veins of the hand

b. place the client's arm in a dependent position

a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include? a. regulate the flow rate by aligning the rate with the top of the ball inside the flow meter b. regulate oxygen via nasal cannula at a flow rate of no more than 6. l/min c. make sure the reservoir bag of a partial rebreathing mask remains deflated d. use petroleum jelly to lubricant the client's nares, face, and lips

b. regulate oxygen via nasal cannula at a flow rate of no more than 6. l/min

a nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care? a. critical pathway b. situation, background, assessment, and recommendation sbar c. transfer report d. medication administration record mar

b. situation, background, assessment, and recommendation sbar

a nurse is performing a home safety assessment for a client who his receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment

b. the client identifies the location of a fire extinguisher

a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? a. they allow the court to overrule an adult client's refusal of medical treatment b. they indicate the form of treatment a client is willing to accept in the event of a serious illness c. they permit a client to withhold medical information from healthcare personnel d. they allow health care personnel in the emergency department to stabilize a client's condition

b. they indicate the form of treatment a client is willing to accept in the event of a serious illness

a nurse is teaching a client and his family how to care for the clients tracheostomy at home. which of the following instructions should the nurse include in the teaching? a. remove the outer canal cautiously for. routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing teach care at home d. cleanse. irritated skin with full strength liquid hydrogen peroxide

b. use tracheostomy covers when outdoors

a nurse is educating a client who has a terminal illness about declining resuscitation in a living will. the client asks, what would happen if I arrived at the emergency and I had difficulty breathing? which of the following responses should the nurse make ? a. we would consult the person appointed by your health care proxy to make decisions b. we would give you oxygen through a tube in your nose c. you would be unable to change your previous wishes about your care d. we would insert a breathing tube while we evaluate your condition

b. we would give you oxygen through a tube in your nose

a nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and leaves the client's room when the nurse asks the client would like discuss any concerns, the client declines. which of the following statements should the nurse make? a.i will return shortly after document this in your record b. most men live a long time with prostate cancer c. I am available to talk if you should change your mind d. I will make a referral to a cancer support group for you

c. I am available to talk if you should change your mind

a nurse is talking with an older adult client who is contemplating retirement. the client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." which of the following responses should the nurse make? a. you would have so much more time to spend with your family b. you should consider getting a part-time job or doing volunteer work c. Let's talk about how the change in your job status will affect d. why wouldn't you want to retire and relax?

c. Let's talk about how the change in your job status will affect

a nurse is providing discharge teaching to a client about self-administering heparin which of the following instructions should the nurse include in the teaching? a. insert the needle at 15 deg angle b. massage the site following the injection c. administer the shot in the abdomen d. aspirate for blood prior to administration

c. administer the shot in the abdomen

a nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? a. verify the clients name on id band with mar b. call the pharmacy to determine whether the clients meds are available c. compare the clients home meds with prescribed meds d. place thee clients home medication bottles in secure location

c. compare the clients home meds with prescribed meds

a nurse is administering 1L of 0.9 sodium chloride who is post op and has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful? a. increase in hematocrit b. increase in respiratory rate c. decrease in heart rate d. decrease in capillary refill time

c. decrease in heart rate

a client who is post op is verbalizing pain as a 2 on a pain scale of 0-10 which of the following statements should the nurse identify as an indiction that the client understands the preoperative teaching she received about pain management? a. i think i should take my pain medication more often, since it is not controlling my pain b. breathing faster will help me keep my mind off of the pain c. it might help me to listen to music while im lying in bed d. i dont want to walk today because i have some pain

c. it might help me to listen to music while im lying in bed

a nurse is caring for a client who is post op for a. knee arthroplasty and requires the use of thigh length sequential compression sleeves. which of the following actions should the nurse take? a. assist the client into prone position b. set the ankle pressure at 65 mmhg c. make sure two fingers can fit. under the sleeve d. place a sleeve over top of each leg with the opening at the knee

c. make sure two fingers can fit under the sleeve

a nurse is talking with the partner of a client who has dementia. the client's partner expresses frustration. about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? a. role ambiguity b.sick role c. role overload d. role conflict

c. role overload

a nurse his using an open irrigation technique to irrigate a client's indwelling urinary catheter. which of the following actions should the nurse take? a. place the client in side-lying position b. instill 15ml of irrigation fluid onto the. catheter with each flush c. subtract the amount of irrigant used from the client's urine output d. perform the irrigation using a 20ml syringe

c. subtract the amount of irrigant used from the client's urine output

a nurse is evaluating a client's use of a cane. which of the following actions should the nurse identify as an indication of correct use? a. top of the cane is parallel to the clients waist b. when walking, the client moves the cane 46cm forward c. the client holds the cane on the stronger side of the body d. the client moves her stronger limb forward with the cane

c. the client holds the cane on the stronger side of the body

a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement? a. combine client care tasks when caring for multiple clients b. wait until the end of the shift to document client care c. use the planning step of the nursing process to prioritize client care delivery d. allow for interruptions in tasks to discuss client care issues with colleagues

c. use the planning step of the nursing process to prioritize client care delivery

a nurse is caring for a client who requires an ng tube for stomach decompression. which of the following actions should the nurse. take when inserting the ng tube a. position the client with the head of the bed at 30 deg prior to. insertion b.remove the ng tube if the pt starts gagging or choking c. apply suction to the ng tube priorate insertion d. have the client take sips of h20 to promote insertion of ng into the esophagus

d. have the client take sips of h20 to promote insertion of ng into esophagus

a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the client's pain? a. is your pain constant or intermittent b. what would you rate your pain on a scale of 0-10 c. does the pain radiate d. is your pain sharp or dull

d. is your pain sharp or dull

a nurse is caring for a client who is post operative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells. the nurse to continue the client's vital signs every 15 min and report back in 1hr. which of the following actions should the nurse take next. a. document the providers statement in the med record b. complete an incident report c. consult the risk manger at the facility d. notify the nurse manager

d. notify the nurse manager

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. bun 15 b. creatinine 0.8 c. sodium 143 d. potassium 5.4

d. potassium 5.4

a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. which of the following actions should the nurse take? a. discuss the risk factors for colon cancer b. focus teaching on what the client will need to do in the future to mange his illness c. provide the client with written information about the phases of loss and grief d. reassure the client that this is an expected response to grief

d. reassure the client that this is an expected response to grief

a nurse is lifting a. bedside cabinet to move it closer to a client who. is sitting in a chair. to prevent. self injury which of the following actions should the nurse take when lifting the object a. bend at waist b. keep his feet close together c. use his back muscles for lifting d. stand close to the object when lifting

d. stand close to the object when lifting

Droplet precaution equipment

gown, mask, protective eyewear, surgical cap, shoe covers, gloves

a nurse is preparing to apply a dressing to a client who has a stage 2 pressure injury. which of the following types of dressing would you want to use? a. aliginate b. gauze c. transparent d. hydrocolloid

hydrocolloid - promotes healing by creating a moist wound bed

What is feverfew?

is a complementary and alternative way to promote wound healing. anticogulant therapy is a contraindication for. taking feverfew

role play for pt teaching

is a technique that promotes cognitive and affective learning

what is fidelity?

is an agreement by nurses. to follow through with promises made to clients

What is justice?

is fairness in client delivery, including the distribution of resources and care

echinacea

promotes immunity and reduced the risk of infection

ginger

relives nausea

fluid volume deficit

s/s of rapid weak pulse, hypotension, increased respirations, poor skin tugor, slow cap refill, dry mucous membranes, increased Hct and increased urinary specific gravity

correct documentation when saying is subcutaneous

subcut or subcutaneously

how do you document the units of insulin?

the number followed for the word unit(s)

patient has a new diagnosis of a seizure- he is found seizing on the floor you press the call light for help- which do you do first then second 1. a. check bp b. provide privacy c. physical safety 2. a. prn meds b. positioning c. incontinence

the nurse should first address the patients physical safety followed by the patients positioning

What is accountability?

the responsibility of nurses to explain their own actions to their clients and employer

what stage dressing for stage 1? wound

transparent - promotes healing by preventing further friction and shearing

What is role ambiguity?

uncertainty about what is expected when assuming a role

Airborne precautions

used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei