3 C's (Commun./Nursing process, Pulmonary, Med. Adm., Wounds/Skin

A client is diagnosed with hypoxia related to emphysema. The client's adult child will assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?

"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

The nurse is instructing a client with xerostomia (dry mouth) about taking several pills and capsules that have been prescribed. What statement made by the client indicates to the nurse that the client understood the instructions?

"I will take a sip or two of water prior to taking my pills."

The nurse is teaching a client about venlafaxine XR. When the client asks, "What does the XR mean?" what is the appropriate nursing response?

"It means extended release." (is released over a long period of time, to last longer)

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.

- "Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." - "The skin can tolerate considerable pressure without cell death, but for a short periods only." - "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

The client is being discharged, and the nurse is reviewing the newly prescribed medications with the client. Which statement(s) will allow the nurse to evaluate the client's understanding of the medications? Select all that apply.

- "Tell me what time of day you are to take your medications." -"What is the reason you are taking each medications?"

The nurse is administering intramuscular injections to clients. What needle size(s) has the nurse used correctly? Select all that apply.

- 5/8 inch (2-cm) needle for a child in the deltoid site - 1 1/2 inch (3.75-cm) needle for an adult in the deltoid site - 5/8 inch (2-cm) needle for the vastus lateralis site

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply.

- Analyzing data - Identifying patterns - Identifying indicators of potential dysfunction

Which guidelines should the nurse consider when writing outcomes? Select all that apply.

- At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis - The nurse should write outcomes that are brief and specific and support the overall plan of care

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply.

- Draw the shape of the wound with a description - Measure the wound's length and width - Assess color, drainage, presence of pain, or complications

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply.

- Proper client nutrition - 2-hour turn schedule - pressure redistribution support surfaces - client repositioning with a lift

The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply.

- To confirm previously collected data - To reveal changes from previously collected data - To monitor clients' responses to treatment - To help establish a diagnosis

Which nursing actions help improve listening skills when conversing with clients? Select all that apply.

- Using facial expressions and body gestures to indicate attention to what the client is saying - Thinking before responding to the client, even if this creates a lull in the conversation - Listening for themes in the client's comments

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply.

- the client who has a body mass index (BMI) of 34 - the client who is emaciated from self-induced vomiting and food deprivation - the client who has a temperature of 104°F (40°C) and is perspiring - the client who is experiencing an allergic reaction and is scratching the skin

While planning care for a client immediately after surgery, the nurse formulates a nursing diagnosis of "Risk for injury." Which assessment data would be appropriate for the nurse to identify as possible etiologies

- unfamiliarity w/ the hospital environment - effects of pain medications - visual deficit - impaired mobility

The nurse is providing care to an older adult client. Which intervention(s) will the nurse perform to protect the client's skin? Select all that apply.

- wash the perineal area every day - offer fluids every hour while the client is awake - minimize the use of tape on the skin - apply moisturizing lotion to feet and hands daily

After performing an assessment on a client, the nurse determines that the client is having difficulty with airway clearance. The nurse supports this suspicion by listing as evidence: a nonproductive cough, crackles in the lower lobes, and a pulse oximeter reading of 94%. The nurse used which process?

Clustering

The nurse is reading a medication prescription for a drug that is routinely administered every 12 hours. The prescription does not state the frequency of administration. What is the appropriate nursing action and accompanying rationale that guides the nurse's action?

Contact the health care provider to clarify the prescription. Assumptions cannot be made about medication administration and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration.

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.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic (low oxygen levels in the tissue) and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

It can cause the nasal mucosa to dry in case of high flow.

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?

Sp02 is 96%

The health care provider writes a prescription for ampicillin 1 gram every 6 hours for a client. What would cause the nurse to question this medication prescription?

The route is missing.

The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented?

Wait with the client until the medications are taken.

At what point should the nurse perform the first of the three checks of medication administration?

as the nurse reaches for the drug package of container

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?

change in the alveolar-capillary membrane and diffusion