233 final exam

The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective?

I will have four to five small incisions

Which question by the nurse below expresses cultural sensitivity?

"What is typically done in your culture?"

The nurse is examining a 18-year-old female who is complaining of pain, frequency, and urgency when urinating. Which question should the nurse ask the client first?

"are you sexually active?"

Research has shown that the primary reason nurses make medication errors is related to: Select all that Apply

- events that distract the nurse during the administration process - the presence of multiple drugs with similar generic names and trade names

Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply.

- monitor the client for orthostatic hypertension - use standard precautions when caring for a client - institute safety precautions when ambulating the client

Which of the following are physical changes seen at the end-of-life? Select all that apply

- mottling of hands and feet - decrease in urine output - loss of gag reflex - difficulty speaking

The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply.

- place thigh high elastic stockings on the client - encourage coughing with deep breathing - encourage increased oral intake of water daily

Five Delegation rights

- right task - right circumstance - right person - right direction and communication - right supervision and evaluation

An older adult client who had been admitted with a diagnosis of emphysema and COPD has been experiencing shortness of breath and low SaO2 levels, evidenced by pallor and a SaO2 reading of 88%. What would be an appropriate outcome for a nursing diagnosis of Altered oxygen levels related to impaired gas exchange AEB cyanosis and low SaO2 levels?

altered oxygen levels related to impaired gas exchange AEB cyanosis and low SaO2 levels.

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem?

ambulates 10 feet farther each day

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?

antacids

Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the lower leg?

application of elastic compression stockings

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer?

arterial ulcer

The nurse is assessing a patient who is suspected to have left-sided heart failure. Which assessment provides specific information regarding the left-sided heart function?

auscultating lung sounds

J.S. is a 72yo female admitted to the hospital after a mechanical fall at home. She has a history of osteoporosis, hypertension, and cognitive impairment. While checking on her, you notice she is grimacing, and rubbing her left leg. Utilizing the SBAR tool to communicate with the covering provider, what would be considered part of your assessment?

Patient observed grimacing

After receiving change-of-shift report, which patient should the nurse assess first?

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

A student nurse calls the nurse at 1600 and reports that at 1500 her instructor gave the medication for patient A to patient B and the medication for patient B to patient A. The student then hung up. The instructor did not report a medication error and is no longer on the unit. What is the nurse's next best action?

review the medication administration record for each patient prior to performing an assessment

Your patient presents with complaints cloudy nasal drainage, nasal obstruction, facial pain, cough, and ear fullness. These are clinical manifestations of...

rhinosinusitis

The six rights of medication administration include all of the following except:

right physician

A patient has asked for a pain medication to relieve the discomfort from her abdominal incision. She has experienced nausea since this morning, after several bites of her soft-diet breakfast. She last received a dose of her ordered oral analgesic 4 hours ago. The medication, hydrocodone 10 mg PO, is ordered q4h prn. Which of the following rights of drug administration most likely will challenge the nurse caring for this patient?

right route

The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority?

risk for injury

Effective management for sleep apnea include all of the following except

sedatives to induce a deeper sleep

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record?

serosanguineous

Which action violates a principle that is key to proper hand washing at the bedside?

shaking your hands dry over the sink

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client?

shuffling and propulsive

A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take?

sit at the bedside and ask if there is anything the patient needs

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

daily alcohol intake

A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?

daily weight

Of the following factors, which would put a client at greatest risk for impaired skin integrity?

decreased sensation

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

dehydration

The client is complaining of incisional pain. Which intervention should the nurse implement first?

determine when the last pain medication was given

The nurse is caring for an elderly client admitted to the hospital for abdominal surgery and develops a plan of care to prevent respiratory complications. Which factors would lead the nurse to develop this plan of care? Select all that apply.

difficulty coughing up secretions & diminished diaphragmatic function

one month after discharge, a client who had a total hip replacement calls a clinic reporting acute constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. A nurse advise the client to come to the clinic immediately suspecting:

dislocation of the prosthesis

You are assessing a patient suspected of having right-sided heart failure. What assessment finding may indicate right-sided heart failure?

distended neck veins

Clinical assessment of dehydration would be confirmed if you identified:

dry mucous membranes

the nurse is caring for a client diagnosed with GERD. Which interventions should be implemented?

elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with client.

Which interventions are likely to reduce the risk of postoperative atelectasis? (select all that apply)

encourage coughing and deep breathing. Administer pain medication

In the event of a medication error, the nurse's first responsibility is to:

ensure the client's safety

The nurse is assessing the skin of a client and notes the area around the buttocks is reddened and macerated. Which factors may have contributed to this finding? Select all that apply.

fever & urinary incontinence

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

stage II

Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tender, and/or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

stage III

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

Stage IV

It is important for the nurse to assess for which clinical manifestation(s) in a patient who has undergone a total thyroidectomy

- confusion - circumoral numbness - positive chxostek's sign

A patient is using transdermal patches to relieve his mild cardiac pain. Which patient statement demonstrates understanding of the use of transdermal patches?

"I will apply the patch to a different area each time."

Which type of medications cannot be crushed, chewed, or opened? (Select all that apply).

- enteric coated tablets - sustained release tablets - extended release tablets - sublingual

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply.

- Be careful not to injure the legs or feet. - Walk each day to increase circulation to the legs. - Cut down on the amount of fats consumed in the diet.

The nurse enters the client's room who is receiving oxygen at 4 L/min via nasal cannula. What should the nurse do to prevent complications? Select all that apply.

- Ensure the client keeps nasal prongs in the nares. - Pad the oxygen tubing behind the ears. - Assess the nares for excessive dryness.

A client with a nagging chronic cough has no other symptoms other than shortness of breath. Upon assessment, the client mentions having a spouse who is a heavy smoker and smokes approximately two packs per day. When educating the client on the increased risk of cancer, the client quickly states, "I don't breathe in that much smoke." What information should be given to the client? Select all that apply.

- Even small amounts of smoke can cause damage to the vessels and abnormal heart rate - Secondhand smoke leads to increased risk of stroke and increased death from cancer - There is no safe level of exposure to second hand smoke - smoke inhalation can lead to emphysema and COPD

The nurse is providing a workshop at an adult community center about obstructive sleep apnea (OSA). What information should be included as correct? Select all that apply.

- It results in narrowing of one or more sites of the upper airway, resulting in intermittent breathing patterns. - It can increase intrathoracic pressure and lead to decreased tidal volume for several breaths or periods of apnea. - It can be treated by using continuous positive airway pressure (CPAP).

Risk factors for pressure ulcers include... (select all that apply

- Low protein diet - lengthy surgical procedures - fever

A client with a cardiac history is taking a potassium-wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. You expect to evaluate which laboratory values?

- Potassium and blood glucose

What should the nurse include in the assessment of a client admitted with a diagnosis of community-acquired pneumonia? Select all that apply.

- Presence of cough - Amount and color of sputum - Occurrence of fever

Which information should the nurse include when documenting the characteristics of a pressure wound located on the hip of a client? Select all that apply

1. Location of the wound 2. Length, width, and depth 4. Presence of undermining or tunneling 6. Drainage amount, color, consistency, and odor

The client diagnosed with AIDS is experiencing diarrhea. Which interventions should the nurse implement? Select all that apply.

1. Monitor diarrhea, charting amount, character, and consistency 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

What are the goals of infection prevention and control in health care? Select all that apply

1. Protect clients from contagions 2. Lower the cost of health care services. 4. Meet professional standards and guidelines. 5. Protect employees from contracting infections.

Six Rights of Medication Administration

1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation

As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?

Ask if this discussion has been discussed with the healthcare provider

A patient reports waking up very tired even after 8 hours of sleep every night. Which action should the nurse take first?

Ask the patient if they have ever been evaluated for sleep apnea

Which information provides the most reliable data about the effectiveness of airway suctioning

Breath sounds, vital signs, and pulse oximetry before and after suctioning

A patient who is allergic to dogs experiences a sudden asthma attack. Which assessment findings does the nurse expect for this patient?

Breathlessness and difficulty speaking in full sentences

The nurse is having difficulty deciphering the medication prescription written by the provider. What is the best strategy to clarify the information?

Call the provider and ask him or her to clarify the prescription

Which finding should the nurse expect when assessing a patient who has osteoarthritis of the knee?

Discomfort with joint movements

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention but he nurse?

Leaning over to pull on shoes and socks

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Na+ 154 mEq/L (154 mmol/L)

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best?

One pillow is placed under the thighs and two pillows are placed under the lower legs.

The client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to

Place a clean, sterile 4 × 4 over the incision and monitor the drainage.

The student nurse has been assigned to a new client with a medical diagnosis of pneumonia and symptoms of cough, malaise, pleural pain from coughing, discolored sputum, fever, chills, dyspnea, and elevated WBC counts. The student has determined one of the nursing diagnoses should be Ineffective breathing pattern related to pneumonia AEB dyspnea and cough. What is an appropriate intervention for the nurse to take to address this diagnosis?

Position the client for ease of breathing.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

Prolonged bed rest

For a patient who has had a right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Reposition the patient every 1 to 2 hours

Level of prevention that aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encourage personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems.

Secondary

The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring?

Secondary intention

Intact skin with nonblanchable redness of a localized area usually over a bony prominence.

Stage 1

If you're called away when you're about to administer a drug, you should:

Take the drug with you and come back later.

Level of prevention that aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (example: chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life, and their life expectancy.

Tertiary

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?

The clients WBC count is 14,000/mm3

The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment change related to this is most concerning?

The patient feels palpitations and has an irregular pulse

Which of the following assessment findings would help confirm a diagnosis of asthma in a client

Wheezing on inspiration and expiration

You are discharging a patient who is going home with a new continuous oxygen requirement. During your discharge teaching they state "I hate how dry this oxygen makes me" you suggest they...

You can use saline nasal spray to moisten your nares

What finding on the nursing assessment would be associated with a diagnosis of pneumonia in the older adult?

acute confusion

The nurse will perform which action for a wet-to-dry dressing change on a patient s stage 3 sacral pressure injury?

administer a prescribed PRN oral analgesic 30 minutes before the change

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?

administer oil retention enemas

Which problem is most appropriate for the nurse to identify for the client with diarrhea?

alteration in skin integrity

The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient

calls the clinic when the weight increases from 124 to 130 pounds a week

A patient comes to the clinic complaining of frequent watery stools for the past 2 days. Which action should the nurse take first?

check the patient's blood pressure

The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement

contact precautions

In a patient with prolonged vomiting, the nurse monitors for fluid volume deficit because vomiting results in

fluid movement from the cells into the interstitial space and the blood vessels

Implementation of nursing care for a patient with hyponatremia includes

fluid restriction

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?

fluid volume deficit (hypovolemia)

The single most important action in preventing the spread of infection is?

frequent hand washing

The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications?

give around the clock routine administration of analgesics

When removing personal protective equipment (PPE) the first item to be removed is?

gloves

Sequence for Doffing PPE

gloves, gown, goggles, mask, hair covering, shoe covering, wash hands

The nurse demonstrates cultural awareness by which behavior?

having an appreciation of cultural arts and dress

Which is the leading cause of complications of hospital care?

hospital-acquired infections

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

increase the fluids if your mouth feels dry

The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says "Im busy at work but otherwise things are fine". Which nursing diagnosis is most important?

ineffective coping related to lack of grieving

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

infuse the KCl at a rate of 10mEq/hour

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following orders are written in the client's electronic health record. Which one should the nurse question?

restrict oral intake to 900ml every 24 hr

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. The patient seems confused and short of breath with peripheral edema. Which assessment should the nurse complete first?

mental status

Long term vs short term goals

must include time frame if pt. doesn't meet them they must be revised

A patient who had open reduction and internal fixation (ORIF) of left lower leg continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and feet is cool to the touch. Which action should the nurse take next?

notify the health care provider

Which menu choice by a patient with osteoporosis indicates the nurses's teaching about appropriate diet has been effective?

oatmeal with skim milk and fruit yogurt

Which respiratory disorder can be diagnosed with the help of polysomnography?

obstructive sleep apnea

which of the following would you consider a long-term goal?

patient's wound will show granulation in 30 days

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention?

place a mattress sensor pad on the bed

The nurse is caring for a patient who is experiencing an acute asthma attack. He is dyspneic and experiencing orthopnea, his pulse rate is 120 beats/minute. The nurse's FIRST action should be...

place in semi-fowler' postition

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes wandering away from home. Which action will the nurse include in the plan of care?

place the patient in a room close to the nurse's station

The client presents to the outpatient clinic complaining of diarrhea for two days. Which laboratory data should the nurse monitor?

potassium levels

An order says: "Administer Morphine 1 mg IV q4hr PRN for pain rating greater than 5 on 1-10 scale." The patient's last dose what at 1200. It is now 1600. The patient's pain rating is currently a 7 on 1-10 scale, and the patient requests pain medication. Your next nursing action is?

prepare to administer Morphine 1 mg IV now

Level of prevention that aims to prevent disease or injury before it occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur.

primary

D.B is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An intervention for him is to:

promote orientation at every encounter with the patient by asking the day, time, and place

The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation?

the client has become confused and irritable

Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective?

the client prepares a scheduled voiding plan

The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client?

the client will function at the highest level of independence possible throughout their stay

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is mostimportant for the nurse to report to the health care provider?

the patient is experiencing laryngeal stridor

he patient is ordered to receive a pain medication patch that is applied to the skin. What route is this medication administered

transdermal

The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic,begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?

turn the client to the side

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

unstageable

The nurse is caring for a postoperative client with an oxygen saturation of 90% who has fine crackles in both lung bases. Which intervention would be most effective in improving this client's respiratory status?

use an incentive spirometer

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

use an indirect light source and turn off the television

The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect?

usually asymptomatic until a target organ is involved

A patient with chronic obstructive pulmonary disease (COPD) is prescribed 24% oxygen. What is the most appropriate oxygen delivery method for this patient?

venturi mask

The male client tells the nurse he has been having "heartburn" at night that awakens him. Which assessment question should the nurse ask?

what have you done to alleviate the heartburn?

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client?

whether this is a change in usual level of orientation