AE 1 Final

The patient asks the nurse why food is withheld before surgery. What is the best response by the nurse? "Infection may occur if food or fluid is taken prior to surgery." "Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time." "Distention is a severe complication if food or fluid is taken close to the surgery time." "Obstruction will occur if food or fluid is taken prior to surgery."

"Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time."

The nurse is providing education about nutrition and feeding to the parent of a toddler. Which statement by the child's parent indicates understanding of the education?

"Boiled eggs and pieces of cheese are good snacks for my child." Explanation: Toddlers are often independent and insist on feeding themselves. Appropriate "finger foods" include meatballs, hard-boiled eggs, cooked carrots, fruit slices (without skins), cheese pieces, dry cereal, and crackers. Avoid whole grapes, hot dogs, hard candy, and other foods that could cause choking.

The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements? Select all that apply. "I took my lisinopril this morning." "I took two Tylenol last evening for a headache." "I took two aspirins for joint pain this morning." "I took my Coumadin as usual last evening." "I have not had any metformin for the past week."

"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning."

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?

"My husband and I are ordering a product that has megadoses of vitamins." Explanation: Consuming megadoses (amounts exceeding those considered adequate for health) of vitamins and minerals can be dangerous. This statement requires further nursing teaching. The other statements do not require further teaching.

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? -"Have your heart checked regularly." -"Stop smoking as soon as possible." -"Take your prescribed medication to bring down your sodium levels." -"Eat a nutritious diet."

"Stop smoking as soon as possible." Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

A female client tells the nurse, "I try to consume 2000 calories daily by eating a variety of proteins, carbohydrates, and fats." What is the appropriate nursing response?

"That is a healthy amount of daily caloric intake." Explanation: Healthy adult women on average require 1800 to 2400 cal/day, with a mix of proteins, carbohydrates, and fats. The nurse should affirm the client's dietary choices. Other answers are incorrect and do not counsel the client appropriately.

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? "The benefit of CBE is less time needed on computer charting." "The benefit of CBE is that it demonstrates whether high-quality care is given." "CBE is the best way to protect against lawsuits." "CBE is a relatively new format of documentation in electronic health records."

"The benefit of CBE is less time needed on computer charting." One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation.

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? "We will discuss the new policies at the change-of-shift report." "You will demonstrate the use of the cardiac monitor on the nursing rounds." "You will see the procedure for using the new equipment in the client assignments." "We will be having a team conference to discuss concerns that clients' relatives have raised."

"We will be having a team conference to discuss concerns that clients' relatives have raised." Team conferences are effective communication strategies to discuss the relatives' concerns because this usually involves the multidisciplinary team and the relatives could be involved. Change-of-shift report is incorrect since this is only a summary of each client's condition and current status of care in a discussion between the personnel of the outgoing and incoming shifts. Client assignment identifies the clients for whom the staff person is responsible and describes their care and is therefore incorrect. Nursing rounds is incorrect since this strategy provides the staff the opportunity to observe and converse in the client's presence and boost the client's confidence.

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history? "Did you bring any valuables with you?" "Who is here with you?" "When is the last time you ate or drank?" "Did you bring a copy of your health care power of attorney?"

"When is the last time you ate or drank?"

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is: -"Nicotine patches would be appropriate for you." -"Have you tried to quit smoking before?" -"I can refer you to the American Lung Association." -"Many options are available for you."

-"Have you tried to quit smoking before?" All the options are appropriate statements; however, the nurse needs to assess the client's statement further. Assessment data include information about previous attempts to quit smoking.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as -Atelectasis -Emphysema -Pleurisy -Pneumonia

-Atelectasis Retention of secretions and subsequent obstruction ultimately cause the aveoli distal to the obstruction to collapse (atelectasis).

Which of the following is a symptom diagnostic of emphysema? -Dyspnea -Copious sputum production -Normal elastic recoil -The occurrence of cor pulmonale

-Dyspnea Dyspnea is characteristic of emphysema. A chronic cough is considered the primary symptom of chronic bronchitis. Refer to Table 11-1 in the text.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? -Respiratory alkalosis -Metabolic alkalosis -Respiratory acidosis -Metabolic acidosis

-Respiratory acidosis As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is: -Sharp, stabbing chest pain -Dyspnea -A dry, hacking cough -Tachycardia

-Sharp, stabbing chest pain The initial symptom is usually chest pain of sudden onset that leads to feelings of chest pressure, dyspnea, and tachycardia. A cough may be present.

A commonly prescribed methylxanthine used as a bronchodilator is which of the following? -Theophylline -Levalbuteral -Terbutaline -Albuteral

-Theophylline Theophylline is an example of a methylxanthine. All the others are examples of inhaled short-acting beta2 agonists.

The classification of grade I COPD is defined as -mild COPD. -moderate COPD. -severe COPD. -very severe COPD.

-mild COPD. Grade I is mild COPD. Grade II is moderate COPD. Grade III is severe COPD. Grade IV is very severe COPD.

Effective documentation should be? (7)

1) Objective 2) Legible 3) Specific 4) Unaltered 5) Consistent 6) Chronological 7) Accurate

What is the BMI of a client who is 1.68 meters tall and weighs 70kg?

24.8

A patient undergoes induction for general anesthesia at 8:30 a.m. and is being assessed continuously for the development of malignant hyperthermia. At which time would the patient be most likely to exhibit manifestations of this condition? 10:00 to 10:10 a.m. 8:40 to 8:50 a.m. 9:00 to 9:10 a.m. 9:30 to 9:40 a.m.

8:40-8:50

You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear? Anxiety and fear increases the need for anesthesia and postoperative medications. Anxiety and fear can affect a client positively during and after surgery. Anxious clients have a poor response to surgery and are prone to complications. Anxious clients need psychological counseling after surgery.

Anxious clients have a poor response to surgery and are prone to complications.

You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear? Anxious clients need psychological counseling after surgery. Anxiety and fear can affect a client positively during and after surgery. Anxiety and fear increases the need for anesthesia and postoperative medications. Anxious clients have a poor response to surgery and are prone to complications.

Anxious clients have a poor response to surgery and are prone to complications.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Calling the client information desk to find out the room number of the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Asking the emergency department nurse for information on the family member Accessing the electronic health record of the family member to find out extent of injury

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? Surgeon Scrub nurse Circulating nurse Registered nurse first assistant

Circulating nurse

What is the DAR format?

Data, action, response

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period? At the time of discharge instructions Following the surgical procedure During the preoperative period Upon arrival to the surgical unit

During the preoperative period

A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed?

Hematocrit 35% Explanation: The hematocrit level of this client is low. Normal hematocrit is 40%-50%. The normal value for hemoglobin is 12-18 mg/dL. The normal value for transferrin is 240-480 mg/dL. The normal blood urea nitrogen is 17-18 mg/dL.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? Discuss concerns regarding the comments with the charge nurse. Report the resident to the attending surgeon. Inform the resident that all communication needs to remain professional. Ignore the comment.

Inform the resident that all communication needs to remain professional

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? -International normalized ratio greater than 2 -Two hour time period of the stroke -Taking digoxin -Surgery 6 weeks ago

International normalized ratio greater than 2 The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.

The nurse understands that the purpose of the "time out" is to: maintain the safety of the client. verify all necessary supplies are available. identify the client's allergies. clarify the roles of the OR personnel.

Maintain the safety of the client

What are the four components of the RAI?

Minimum data set, triggers, resident assessment protocols and utilization guidelines

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults? Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults. All older people face similar risks when undergoing surgeries. Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. Aging processes reduce the chances that surgery will be successful for these clients.

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

What does OASIS stand for?

Outcome and Assessment Information Set

The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time? Place the side rails in the up position and make sure the call button is in reach. Have the family go to the waiting room. Take the client to the bathroom. Take the client's vital signs.

Place the side rails in the up position and make sure the call button is in reach.

When is the ideal time to discuss preoperative teaching When the patient is comfortable and sedated Prior to entering the pre-op area Preadmission visit Day of surgery

Preadmission visit

What is it called when a nurse provides proactive, systematic, nurse-driven, evidence-based interventions that help the nurse to anticipate and address patient needs?

Purposeful rounding

A client is preparing to undergo a curative surgical procedure. Which of the following is the type of surgery the client could be having? Select all that apply. Removal of a diseased appendix Skin biopsy Mammoplasty Removal of a tumor Insertion of a gastrostomy tube

Removal of a tumor Removal of a diseased appendix

*In this PIE chart note, what is the "P"?* - Risk for trauma related to dizziness - Instructed to call for assistance when getting OOB. Call light in reach. - Consistently calls for assistance when getting OOB and continues to experience dizziness (OOB = Out of Bed)

Risk for trauma related to dizziness

The nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing? PIE note flow sheet narrative note SOAP note

SOAP note SOAP note is a progress note that relates to only one health problem.

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? Scrub role Registered nurse first assistant Anesthetist Circulating nurse

Scrub Nurse

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? -High-Fowler's -Prone -Supine -Semi-Fowler's

Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Pulse rate of 110 beats/min Temperature of 102.5°F (39°C) Respiratory rate of 18 breaths/min Blood pressure of 104/62 mm Hg

Temperature of 102.5

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Anesthesiologist Surgeon Scrub nurse Circulating nurse

The circulating nurse

The client is prescribed albuterol (Ventolin) 2 puffs as a metered-dose inhaler. The nurse evaluates client learning as satisfactory when the client

To administer a metered-dose inhaler, the client holds the inhaler upright and shakes the inhaler. The inhaler is positioned 1 to 2 inches away from the client's open mouth. After administering the medication, the client holds the breath for as long as possible, at least 10 seconds. The client may administer the next puff in 15 to 30 seconds.

What is the primary purpose of the patient record?

To assist healthcare providers from different disciplines to communicate with one another and ensure the continuity of effective care.

What is the purpose of progress notes?

To inform caregivers of the progress a patient is making toward achieving expected outcomes

The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element?

Vitamin A

At what period of life do nutrient needs stabilize?

adulthood

A nurse is reviewing a client's lab results. Which lab values would be indicative of a client's level of malnutrition? a. hemoglobin b. serum albumin c. creatinine d. oxygen saturation

b. serum albumin

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate? a. allow the cleint privacy during mealtime b. delegate feeding assistance to the UAP c. assess when client generally eats meals d. contact the healthcare provider to prescribe an appetite stimulant

c. assess when client generally eats meals

The nurse is reviewing a client's most recent lab results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is MOST appropriate? a. place the client on calorie restriction b. administer a high-protein diet c. increase the client's fluid intake d. arrange for TPN

c. increase the client's fluid intake

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a) The day before the patient is discharged b) After the patient has passed the acute phase of the stroke c) After the nurse has received the discharge orders d) The day the patient has the stroke

d) The day the patient has the stroke - Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

"If it wasn't ______________, it wasn't done!"

documented

A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be MOST appropriate for this client's needs?

gastrostomy tube

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:

negative nitrogen balance. Explanation: A negative nitrogen balance exists when excretion of nitrogen exceeds the intake.

Which of the following is a fat-soluble vitamin?

vitamin E Explanation: Vitamin E is a fat-soluble vitamin.

A client who has bleeding tendencies has a deficiency in which vitamin?

vitamin K

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." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

"Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is best?

"Can you share an example of what you ate yesterday?" Explanation: Healthy adult client on average require 1,800 to 2,400 cal/day. Unless the caloric intake includes an appropriate mix of proteins, carbohydrates, and fats, the person may be marginally nourished or malnourished. In other words, consuming 2,400 calories of chocolate, exclusive of any other food, is not adequate to sustain a healthy state. By asking the client for an example of the foods eaten, the nurse can help the client plan effectively. It is important to teach clients about healthy nutrition, so this response is most appropriate. The other responses from the nurse are not correct.

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? -"Emotional lability is common after a stroke, and it usually improves with time." -"You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." -"This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" -"You sound stressed; maybe using some stress management techniques will help."

"Emotional lability is common after a stroke, and it usually improves with time." This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

A nurse has just completed teaching with a patient who has been prescribed a meter-dosed inhaler for the first time. Which of the following statements would the nurse use to initiate further teaching and follow-up care?

"I do not need to rinse my mouth with this type of inhaler." Mouth-washing and spitting are effective in reducing the amount of drug swallowed and absorbed systemically. Actuation during a slow (30 L/min or 3 to 5 seconds) and deep inhalation should be followed by 10 seconds of holding the breath. The patient should actuate only once. Simple tubes do not obviate the spacer/VHC per inhalation

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Fever, possible urinary tract infection "I don't feel well. I've been urinating often, and it burns when I urinate." Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the health care provider, encourage fluids, and continue to monitor).

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I think the client would benefit from intravenous furosemide."

"I think the client would benefit from intravenous furosemide." Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? "I will arrange access for you to review the record after you put your request in writing." "No, the health care provider will not give you access to review the records." "Are you questioning the care of your child?" "Only the client has the right to review the health care records."

"I will arrange access for you to review the record after you put your request in writing." Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the health care provider not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." "I will stay logged in on the computer until the end of my shift." "I will elaborate on the details on my entry in the clients' records."

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." Writing, printing, or typing information legibly will prevent the entry from losing its value for exchanging information if it is unreadable. Using only agency-approved abbreviations promotes consistency in interpretation. Drawing a straight line through any blank space will reduce the possibilities that someone else will add information to the current documentation. Staying logged in on the computer until the end of the shift is incorrect, as it is a security risk. Best practice is that the nurse logs off each time the nurse has completed an entry. Elaborating on the details on the entry in the clients' records is not in keeping with best practice. The entry should be brief but complete.

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will allow for us to see the client and possibly increase client participation in care." "It will let me see everything that has been done and things that need to be done." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will give me a better sense of what my workload will be today."

"It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? "Legal policy requires nursing practice to be permanently integrated into the client record." "It would be easier to do it that way. You could develop a tool to use." "The facility requires us to document client care this way because of the computer application used." "The electronic health record we use does not allow us to use different formats."

"Legal policy requires nursing practice to be permanently integrated into the client record." Legal policy requires nursing care documentation to be permanently integrated into the client record. Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develop a new tool would be inappropriate, as separate nursing documentation would not be legal.

Which nursing statement would best decrease a client's anxiety before an emergency operative procedure? "You will be just fine; the operating room nurses will take good care of you." "We will keep your family informed of your progress." "It is best to take deep breaths and relax before the procedure." "Let me explain to you what will happen next."

"Let me explain to you what will happen next."

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them." "Vital signs do not need to be recorded unless they are abnormal." "The UAP logs in under my name and documents the vital signs." "The UAP is able to log in and enter the information so all members of the health care team can see it."

"The UAP is able to log in and enter the information so all members of the health care team can see it." Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.

A client informs the nurse that they have been following a strict low-calorie diet and skipping meals to lose weight faster. The client reports upset about not losing any weight and want to know what to do. What is the BEST response by the nurse?

"The body will go into starvation mode by slowing metabolic rate and it will be hard to lose weight."

The nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply. "I have diagnosed the client with an internal bleed and need orders to treat accordingly." "The client demonstrates additional signs of hypovolemia including slow capillary refill." "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery." "The client is very distressed. I am very concerned about how the client is coping right now."

"The client demonstrates additional signs of hypovolemia including slow capillary refill." "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery." When notifying the health care provider about a change in a client's condition, the nurse documents in the client's record the information reported and the instructions received. In an effort to improve client safety by improving staff communication and identifying client safety risks, the SBAR format has been recommended as a model for effective communication. SBAR refers to S (Situation): What is the situation about which you are calling, B (Background): Pertinent background information related to the situation, A (Assessment): What is your assessment of the situation?, R (Recommendation): Explain what is needed or wanted. The SBAR does not require the nurse to formulate a medical diagnosis. It is not within the nurse's scope to conclude that the client has an internal bleed, instead, the nurse would make a recommendation for what is needed, for example, for the health care provider to attend the client and assess further. While it is important to respond to the client's needs, if they are distressed, the nurse will not include this information in the SBAR because it does not focus on the issue that needs to be immediately prioritized which is the sudden hypotension.

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? "No medical issues overnight that require immediate attention." "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety."

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." In inpatient settings, the handoff that occurs when a new shift starts is often referred to as the change-of-shift report. This ensures continuity of client care from one shift to the next, allowing the oncoming nurse to receive information regarding the client's status or plan of care. The handoff should include objective information regarding the status of the client such as mental status, pain issues, and care performed. Subjective information is also in the handoff. This includes statements regarding anxiety. Brief, undescriptive statements are not comprehensive enough and positioning of the client, while important, is not thorough enough. Statement regarding restlessness may be important and the provider may need to be contacted, but this is not the most effective way to communicate information needed in the hand-off.

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? "The clients' medical records provide data for legal evidence." "I can share the clients' medical records with the health care team." "The clients' medical records are an obstruction to research and education." "The clients' health records should be used to promote reimbursement from insurance companies"

"The clients' medical records are an obstruction to research and education." The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? "My medical records will be sent to the ambulatory care center prior to my surgery." "The nurse will explain the details of the surgery before I sign a consent." "The physician will update my family after the procedure and provide specific discharge instructions." "If I do not follow the instructions, my surgery could be cancelled."

"The nurse will explain the details of the surgery before I sign a consent."

The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective?

"When I take my medication, I will eat a banana or take it with a glass of orange juice." Explanation: The client demonstrates that the teaching was effective by identifying bananas and orange juice as foods rich in potassium. The desired effect of the medication is to excrete sodium to avoid the accumulation of fluid in the lungs. To increase the amount of salt in the diet would be counterproductive. Dairy products such as milk and cheese are not potassium-rich foods. Eating small frequent meals versus three meals per day is irrelevant in increasing potassium level.

The parent of a 16-year-old client asks the nurse, "How could the surgeon operate without my consent?" What is the best response by the nurse? "Your child had life-threatening injuries that required immediate surgery." "Two doctors decided your child needed the surgery, therefore we did not need to get consent." "We obtained consent from your child after your child requested the surgery." "The surgical procedure being performed does not require consent."

"Your child had life-threatening injuries that required immediate surgery."

A nurse is caring for a client receiving TPN. Which should the nurse educate the client about regarding TPN therapy?

- TPN has three primary components: proteins, carbohydrates, and fats - TPN has a high glucose concentration - TPN requires a PICC line or central venous access

The nurse is attempting to insert an NG tube and, as the tube is passing the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in thus situation?

- ask the client if he needs to pause before continuing insertion - continue to advance the tube when the client relates that he is ready - have the emesis basin nearby in case the client begins to vomit

A nurse who is planning a diet for a client who has anorexia chooses nutrients that supply energy to the body. Which nutrients are these?

- carbohydrates - protein - lipids

The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend the client to avoid?

- cured ham - table salt - bacon

A nurse is working with a client who is interested in losing weight and asks the nurse why trans fats are so bad for you. What is the BEST response by the nurse?

- trans fats lower HDL levels - trans fats raise LDL levels - trans fats raise cholesterol levels

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue? -"Raise your arms over your head." -"Delay self-care activities for 1 hour." -"Sit in a chair whenever doing an activity." -"Drink fluids upon arising from bed."

-"Delay self-care activities for 1 hour." Some clients with COPD have shortness of breath and fatigue in the morning on arising as a result of bronchial secretions. Planning self-care activities around this time may be better tolerated by the client, such as delaying activities until the client is less short of breath or fatigued. The client raising the arms over the head may increase dyspnea and fatigue. Sitting in a chair when bathing or dressing will aid in dyspnea and fatigue but does not address the situation upon arising. Drinking fluids will assist in liquifying secretions which, thus, will aid in breathing, but again does not address the situation in the morning.

The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction? -"Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." -"I can't use a spacer or holding chamber with the MDI." -"I will take a slow, deep breath in after pushing down on the MDI." -"I will shake the MDI container before I use it."

-"I can't use a spacer or holding chamber with the MDI." The client can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining client statements are accurate and indicate the client understands how to use the MDI correctly.

A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication? -"I can stop using this drug when I begin to feel better." -"I should use this inhaler whenever I get short of breath." -"I need to hold my breath as long as possible after I take a deep inhalation." -"I need to call the physician right away if I feel my heart beating fast after using the drug."

-"I need to hold my breath as long as possible after I take a deep inhalation." The client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli. Metaproterenol (Alupent) needs to be used over an extended period for maximum effect. The client shouldn't use the inhaler whenever he feels out of breath because dependency can develop if the drug is used excessively. The client should adhere to the prescribed dosage. Tachycardia is an expected adverse reaction to metaproterenol. The client should be taught how to monitor his heart rate and contact the physician only if the heart rate exceeds 130 beats/minute.

Which statement describes emphysema? -A disease of the airways characterized by destruction of the walls of overdistended alveoli -A disease that results in reversible airflow obstruction, a common clinical outcome -Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years -Chronic dilatation of a bronchus or bronchi

-A disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of COPD. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

Which statement describes emphysema? -A disease of the airways characterized by destruction of the walls of overdistended alveoli -A disease that results in reversible airflow obstruction, a common clinical outcome -Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years -Chronic dilatation of a bronchus or bronchi

-A disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of alveoli; a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

Which of the following is accurate regarding status asthmaticus? -A severe asthma episode that is refractory to initial therapy -Patients have a productive cough. -Usually occurs with warning -Usually does not progress to severe obstruction

-A severe asthma episode that is refractory to initial therapy Status asthmaticus is a severe asthma episode that is refractory to initial therapy. It is a medical emergency. Patients report rapid progressive chest tightness, wheezing, dry cough, and shortness of breath. It may occur with little or no warning.

A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? -Ipratropium bromide -Fluticasone propionate -Ipratropium bromide and albuterol sulfate -Albuterol

-Albuterol Albuterol (Proventil), a SABA, is given to asthmatic patients for quick relief of symptoms. Ipratropium bromide (Atrovent) is an anticholinergic. Ipratropium bromide and albuterol sulfate (Combivent) is a combination SABA/anticholinergic, and Fluticasone propionate (Flonase) is a corticosteroid.

In which statements regarding medications taken by a client diagnosed with COPD do the the drug name and the drug category correctly match? Select all that apply. -Albuterol is a bronchodilator. -Dexamethasone is an antibiotic. -Cotrimoxazole is a bronchodilator. -Ciprofloxacin is an antibiotic. -Prednisone is a corticosteroid.

-Albuterol is a bronchodilator. -Ciprofloxacin is an antibiotic. -Prednisone is a corticosteroid. Theophylline, albuterol, and atropine are bronchodilators. Dexamethasone and prednisone are corticosteroids. Amoxicillin, ciprofloxacin, and cotrimoxazole are antibiotics. All of these drugs could be prescribed to a client with COPD.

After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options. -Alter smooth muscle tone -Reduce airway obstruction -Decrease alveolar ventilation -Increase oxygen distribution

-Alter smooth muscle tone -Reduce airway obstruction -Increase oxygen distribution Bronchodilators relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis? -Anxiety -Imbalanced nutrition: More than body requirements -Impaired swallowing -Unilateral neglect

-Anxiety In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take? -Aspirates for blood return before injecting the medication -Assesses fasting blood glucose levels -Encourages the client to decrease caloric intake due to increased appetite -Informs the client to limit fluid intake due to fluid retention

-Assesses fasting blood glucose levels Adverse effects of methylprednisolone (Solu-Medrol) include abnormalities in glucose metabolism. The nurse monitors blood glucose levels. Methylprednisolone also increases the client's appetite and fluid retention, but the client will not decrease caloric or fluid intake as a result of these adverse effects. It is not necessary to aspirate for blood return prior to injecting the medication, because doing so would not support the intravenous line in the vein.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for? -Atelectasis -Emphysema -Pleurisy -Pneumonia

-Atelectasis In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

Which statement is true about both lung transplant and bullectomy? -Both procedures cure COPD. -Both procedures treat end-stage emphysema. -Both procedures treat patients with bullous emphysema. -Both procedures improve the overall quality of life of a client with COPD.

-Both procedures improve the overall quality of life of a client with COPD. Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.

Which of the following occupy space in the thorax, but do not contribute to ventilation? -Bullae -Alveoli -Lung parenchyma -Mast cells

-Bullae Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax. Bullae may compress areas of healthier lung and impair gas exchange. Alveoli are the functional units of the lungs. Lung parenchyma is lung tissue. Mast cells, when activated, release several chemicals called mediators that include histamine, bradykinin, prostaglandins, and leukotrienes.

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse? -Collects sputum for culture and sensitivity -Administers vancomycin intravenously -Provides nebulized tobramycin (TOBI) -Gives oral pancreatic enzymes with meals

-Collects sputum for culture and sensitivity Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. -Compromised gas exchange -Decreased airflow -Wheezes -Jugular vein distention -Ascites

-Compromised gas exchange -Decreased airflow -Wheezes Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations? -Albuterol -Cromolyn sodium -Levalbuterol HFA -Ipratropium

-Cromolyn sodium Cromolyn sodium is contraindicated in clients with acute asthma exacerbation. Indications for cromolyn sodium are long-term prevention of symptoms in mild, persistent asthma; it may modify inflammation. Cromolyn sodium is also a preventive treatment before exposure to exercise or a known allergen. Albuterol, levalbuterol HFA, and ipratropium can be used to relieve acute symptoms.

Although many signs and symptoms lead to a diagnosis of emphysema, one symptom stands as the primary presenting symptom. Which of the following is the primary presenting symptom? -Chronic and persistent cough -Dyspnea -Tachypnea -Wheezing

-Dyspnea Dyspnea may be severe and often interferes with the patient's activities. It is usually progressive, worse with exercise, and persistent. As COPD progresses, dyspnea may occur at rest. Chronic cough and sputum production often precede the development of airflow limitation by many years. However, not all people with cough and sputum production develop COPD. The cough may be intermittent and unproductive in some patients.

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder? -Asthma -Bronchiectasis -Cystic fibrosis -Emphysema

-Emphysema COPD may include diseases that cause airflow obstruction (eg, emphysema, chronic bronchitis) or any combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of COPD are now classified as chronic pulmonary disorders. Asthma is now considered a distinct, separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation.

The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client -Exhales hard and fast with a single blow -Inhales deeply and holds the breath -Records in a diary the number achieved after one breath -Sits in a straight-back chair and leans forward

-Exhales hard and fast with a single blow To use a peak flow meter, the client stands. Then the client takes a deep breath and exhales hard and fast with a single blow. The client repeats this twice and records a "personal best" in an asthma diary.

Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)? -Exposure to tobacco smoke -Occupational exposure -Passive smoking -Ambient air pollution

-Exposure to tobacco smoke Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors but do not account for the majority.

Which exposure accounts for most cases of COPD? -Exposure to tobacco smoke -Occupational exposure -Passive smoking -Ambient air pollution

-Exposure to tobacco smoke Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors, but they do not account for most cases.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client -Has wheezes in the right lung lobes -Has a respiratory rate of 28 breaths/minute -Reports shortness of breath -Cannot perform activities of daily living

-Has wheezes in the right lung lobes Of the data listed, wheezing, an adventitious lung sound, is the best datum that supports the diagnosis of ineffective airway clearance. An increased respiratory rate and a report of dyspnea are also defining characteristics of this nursing diagnosis. They could support other nursing diagnoses, as would inability to perform activities of daily living.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? -Full-liquid -High-protein -1,800-calorie ADA -Low-fat

-High-protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted? -I -II -III -IV

-I COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1/FVC <70% and FEV1 ≥80% predicted. Grade II (moderate): FEV1/FVC <70% and FEV1 50% to 80% predicted. Grade III (severe): FEV1/FVC <70% and FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1/FVC <70% and FEV1 <30% predicted.

A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action? -Move the indicator to the top of the numbered scale. -Sit down while completing a peak flow reading. -Take and record peak flow readings three times daily. -If coughing occurs during the procedure, repeat it.

-If coughing occurs during the procedure, repeat it. Steps for using the peak flow meter correctly include (1) moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing the mouthpiece in the mouth and closing the lips around it; (5) blowing out hard and fast with a single blow; and (6) recording the number achieved on the indicator. If the client coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects? -Disturbed sleep pattern related to cough -Ineffective coping related to anxiety -High risk for ineffective therapeutic regimen management related to lack of knowledge -Activity intolerance related to fatigue

-Ineffective coping related to anxiety Any factor that interferes with normal breathing quite naturally induces anxiety, depression, and changes in behavior. Constant shortness of breath and fatigue may make the patient irritable and apprehensive to the point of panic. Although the other choices are correct, the most important psychosocial nursing diagnosis for a patient with COPD is ineffective coping related to a high level of anxiety.

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. -Inflamed airways that obstruct airflow -Mucus secretions that block airways -Overinflated alveoli that impair gas exchange -Dry airways that obstruct airflow -Decreased numbers of goblet cells

-Inflamed airways that obstruct airflow -Mucus secretions that block airways -Overinflated alveoli that impair gas exchange Because of chronic inflammation and the body's attempts to repair it, changes and narrowing occur in the airways. In the proximal airways, changes include increased numbers of goblet cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus. In the peripheral airways, inflammation causes thickening of the airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing.

Which of the following is the key underlying feature of asthma? -Inflammation -Shortness of breath -Productive cough -Chest tightness

-Inflammation Inflammation is the key underlying feature and leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheeze, and dyspnea.

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? -Varicella -Influenza -Hepatitis B -Human papilloma virus (HPV)

-Influenza Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for women ages 9 to 26.

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? -It helps prevent early airway collapse. -It increases inspiratory muscle strength. -It decreases use of accessory breathing muscles. -It prolongs the inspiratory phase of respiration.

-It helps prevent early airway collapse. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by? -Eosiniphils -Lymphocytes -Mast cells -Neutrophils

-Mast cells Mast cells, neutrophils, eosinophils, and lymphocytes play key roles in the inflammation associated with asthma. When activated, mast cells release several chemicals called mediators. One of these chemicals is called histamine.

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments? -Oxygen through nasal cannula at 2 L/minute -Intravenous methylprednisolone (Solu-Medrol) 120 mg -Ipratropium bromide (Alupent) by metered-dose inhaler -Vancomycin 1 gram intravenously over 1 hour

-Oxygen through nasal cannula at 2 L/minute All options listed are treatments that may be used for a client with an exacerbation of COPD. The first line of treatment is oxygen therapy.

The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan? -Restricting oral intake to 1,000 mL/day -Providing the client a low-sodium diet -Performing chest physiotherapy as ordered -Discussing palliative care and end-of-life issues with the client

-Performing chest physiotherapy as ordered Nursing care includes helping clients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, chest physiotherapy, and breathing exercises. In addition, the nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Clients with CF also experience increased salt content in sweat gland secretions; thus it is important to ensure the client consumes a diet that contains adequate amounts of sodium. As the disease progresses, the client will develop increasing hypoxemia. In this situation, preferences for end-of-life care should be discussed, documented, and honored; however, there is no indication that the client is terminally ill.

In COPD, the body attempts to improve oxygen-carrying capacity by increasing the amount of red blood cells. Which term refers to this process? -Emphysema -Asthma -Polycythemia -Bronchitis

-Polycythemia Polycythemia is an increase in the red blood cell concentration in the blood. In COPD, the body attempts to improve oxygen-carrying capacity by producing increasing amounts of red blood cells.

The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication? -Positions the inhaler 2 finger widths away from the lips -Carefully holds the inhaler upright without shaking it -Holds the breath for 5 seconds after administering the medication -Immediately repeats the second puff after the first puff

-Positions the inhaler 2 finger widths away from the lips To administer a metered-dose inhaler, the client holds the inhaler upright and shakes the inhaler. The inhaler is positioned 2 finger widths away from lips. After administering the medication, the client holds the breath for as long as possible, at least 10 seconds. The client may administer the next puff in 15 to 30 seconds.

A child is having an asthma attack and the parent can't remember which inhaler to use for quick relief. The nurse accesses the child's medication information and tells the parent to use which inhalant? -Cromolyn sodium -Theo-Dur -Serevent -Proventil

-Proventil Short-acting beta2-adrenergic agonists (albuterol [AccuNeb, Proventil, Ventolin], levalbuterol [Xopenex HFA], and pirbuterol [Maxair]) are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to moderate anti-inflammatory agents and are considered alternative medications for treatment. These medications stabilize mast cells. These medications are contraindicated in acute asthma exacerbations. Long-acting beta2-adrenergic agonists are not indicated for immediate relief of symptoms. These include theophylline (Slo-Bid, Theo- Dur) and salmeterol (Serevent Diskus).

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment? -Providing sufficient oxygen to improve oxygenation -Avoiding the use of oxygen to decrease the hypoxic drive -Monitoring the pulse oximetry to assess need for early intervention when PCO2 levels rise -Increasing pH

-Providing sufficient oxygen to improve oxygenation The main objective in treating patients with hypoxemia and hypercapnia is to give sufficient oxygen to improve oxygenation.

Which diagnostic test is most accurate in assessing acute airway obstruction? -Arterial blood gases (ABGs) -Pulmonary function studies -Pulse oximetry -Spirometry

-Pulmonary function studies Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression. ABGs and pulse oximetry are not the most accurate diagnostics for an airway obstruction. Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC).

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. -Report changes in neurologic status as soon as a worsening trend is identified. -Use a well-lighted room for assessments every 2 hours. -Follow the healthcare provider's orders to increase fluid volume. -Maintain the head of the bed at 30 degrees. -Avoid any activities that cause a Valsalva maneuver.

-Report changes in neurologic status as soon as a worsening trend is identified. -Maintain the head of the bed at 30 degrees. -Avoid any activities that cause a Valsalva maneuver. Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure? -Respiratory acidosis -Respiratory alkalosis -Metabolic acidosis -Metabolic alkalosis

-Respiratory acidosis In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances? -Respiratory acidosis -Respiratory alkalosis -Metabolic alkalosis -Metabolic acidosis

-Respiratory acidosis Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid-base imbalances would not correlate with COPD.

A nursing student understands that emphysema is directly related to which of the following? -Diminished alveolar surface area -Hypercapnia resulting from decreased carbon dioxide tension -Hypoxemia secondary to impaired oxygen diffusion -Respiratory acidosis from airway obstruction

-Respiratory acidosis from airway obstruction In the later stages of emphysema, carbon dioxide elimination is impaired, resulting in increased carbon dioxide tension in arterial blood (hypercapnia) leading to respiratory acidosis.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? -Respiratory rate of 22 breaths/minute -Dilated and reactive pupils -Urine output of 40 ml/hour -Heart rate of 100 beats/minute

-Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

A nursing instructor is discussing asthma and its complications with medical-surgical nursing students. Which of the following would the group identify as complications of asthma? Choose all that apply. -Status asthmaticus -Respiratory failure -Pertussis -Atelectasis -Thoracentesis

-Status asthmaticus -Respiratory failure -Atelectasis Complications of asthma may include status asthmaticus, respiratory failure, pneumonia, and atelectasis. Pertussis and pneumothorax are not complications.

To help prevent infections in clients with COPD, the nurse should recommend vaccinations against two bacterial organisms. Which of the following are the two vaccinations? -Streptococcus pneumonia and Haemophilus influenzae -Streptococcus pneumonia and varicella -Haemophilus influenzae and varicella -Haemophilus influenzae and Gardasil

-Streptococcus pneumonia and Haemophilus influenzae Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for females ages 9 to 26 years.

The nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). The nurse instructs the client as follows: (Select all that apply.) -Take a slow, deep inhalation from the device. -Use normal inhalations with the device. -Activate the MDI once. -The device may increase delivery of the MDI medication. -It is not necessary to hold your breath after using.

-Take a slow, deep inhalation from the device. -Activate the MDI once. -The device may increase delivery of the MDI medication. The pictured device is a spacer, which is attached to an MDI for client use. The client activates the MDI once and takes a slow, deep inhalation, not normal inhalations. The client then holds the breath for 10 seconds. The spacer may increase delivery of the MDI medication.

A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority? -Avoid contact with fur-bearing animals. -Change filters on heating and air conditioning units frequently. -Take ordered medications as scheduled. -Avoid goose down pillows.

-Take ordered medications as scheduled. Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks.

Why would a client with COPD report feeling fatigued? Select all that apply. -The client is using all expendable energy just to breathe. -Muscle function gradually decreases over time in clients with COPD. -The client is using all expendable energy for activities of daily living (ADLs). -Lung function gradually decreases over time in clients with COPD.

-The client is using all expendable energy just to breathe. -Lung function gradually decreases over time in clients with COPD. The client is using all expendable energy just to breathe. Lung function, not muscle function, gradually decreases over time in clients with COPD. In a client with COPD, fatigue and a feeling of exhaustion stem directly from the disease, not from activity level.

The nurse is instructing the patient with asthma in the use of a newly prescribed leukotriene receptor antagonist. What should the nurse be sure to include in the education? -The patient should take the medication with meals since it may cause nausea. -The patient should take the medication separately without other medications. -The patient should take the medication an hour before meals or 2 hours after a meal. -The patient should take the medication with a small amount of liquid.

-The patient should take the medication an hour before meals or 2 hours after a meal. The nurse should instruct the patient to take the leukotriene receptor antagonist at least 1 hour before meals or 2 hours after meals.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? -Encouraging the client to drink three glasses of fluid daily -Keeping the client in semi-Fowler's position -Using a Venturi mask to deliver oxygen as ordered -Administering a sedative as ordered

-Using a Venturi mask to deliver oxygen as ordered The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.

A cient with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed? -After meals and at bedtime -Before meals -With meals -Three times a day regardless of meal time

-With meals Nearly 90% of clients with cystic fibrosis have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals.

A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes -teaching the family how to perform postural drainage. -instructing the client on the signs of respiratory infection. -implementing measures to clear pulmonary secretions. -providing the client a low-calorie, high-fiber diet.

-implementing measures to clear pulmonary secretions. Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Although teaching the family how to perform postural drainage and instructing the client on the signs of respiratory infection are important, they are not the nurse's primary focus. The presence of a large amount of mucus may decrease the client's appetite and result in inadequate dietary intake; therefore, the client's nutritional status is assessed and strategies are implemented to ensure an adequate diet.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: -instruct the client to drink at least 2 L of fluid daily. -maintain the client on bed rest. -administer anxiolytics, as ordered, to control anxiety. -administer pain medication as ordered.

-instruct the client to drink at least 2 L of fluid daily. Mobilizing secretions is crucial to maintaining a patent airway and maximizing gas exchange in the client with COPD. Measures that help mobilize secretions include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity. Anxiolytics rarely are recommended for the client with COPD because they may cause sedation and subsequent infection from inadequate mobilization of secretions. Because COPD rarely causes pain, pain medication isn't indicated.

The classification of Stage II of COPD is defined as -at risk for COPD. -moderate COPD. -severe COPD. -very severe COPD. -mild COPD.

-moderate COPD. Stage II is moderate COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage III is severe COPD. Stage IV is very severe COPD.

A client is being admitted to an acute healthcare facility with an exacerbation of chronic obstructive pulmonary disease (COPD). The client had been taking an antibiotic at home with poor relief of symptoms and has recently decided to stop smoking. The nurse is reviewing at-home medications with the client. The nurse is placing this information on the Medication Reconciliation Record. Which of the following is incomplete information? -nicotine patch (Nicoderm) 21 mg 1 patch daily at 0800 -salmeterol/fluticasone (Seretide) MDI daily at 0800 -azithromycin (Zithromax) 600 mg oral daily for 10 days at 0800, on day 4 -prednisone 5 mg oral daily at 0800

-salmeterol/fluticasone (Seretide) MDI daily at 0800 When providing information about medications, the nurse needs to include right drug, right dose, right route, right frequency, and right time. Salmeterol/fluticasone does not include how many puffs the client is to take.

The classification of Stage III of COPD is defined as -at risk for COPD. -mild COPD. -severe COPD. -very severe COPD. -moderate COPD.

-severe COPD. Stage III is severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage IV is very severe COPD.

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include -the importance of blood tests to monitor serum concentrations. -taking the medication at least 1 hour prior to meals. -monitoring liver function studies as prescribed. -development of hyperkalemia.

-the importance of blood tests to monitor serum concentrations. The nurse should inform clients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he: -sits in tripod position. -has a pulse oximetry reading of 93%. -uses the sternocleidomastoid muscles. -wants the head of the bed raised to a 90-degree level.

-uses the sternocleidomastoid muscles. Use of accessory muscles indicates worsening breathing conditions. Assuming the tripod position, a 93% pulse oximetry reading, and a request for the nurse to raise the head of the bed don't indicate that the client's condition is worsening.

The classification of Stage IV of COPD is defined as -at risk for COPD. -mild COPD. -severe COPD. -very severe COPD. -moderate COPD.

-very severe COPD. Stage IV is very severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage III is severe COPD.

A client is prescribed methylprednisolone (Solu-Medrol) 125 mg intravenously. The medication is available in a 125 mg single-dose vial containing 2 mL. The nurse will administer methylprednisolone over 2 minutes. How many mL will the nurse administer each 15 seconds? Write your answer to 2 decimal places. Starting with 0., enter the correct number ONLY.

0.25 The volume to be infused is 2 mL over 2 minutes. There are 60 seconds in each minute. For every 15 seconds, the nurse will administer 0.25 mL. 2 mL/120 sec = x/15 sec. 0.25 mL = x

Which is the proper way to document midnight in a client's record? 0000 2401 1200 1201

0000 0000 is the military time for midnight and is correct. The other military times are incorrect since 2401 is 1 minute past midnight, 1200 is noon, and 1201 is 1 minute past noon.

The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information? Sertraline 100 mg per os HS 20:00. JD, RN. 0800-Amoxicillin 250mg PO with water. J. Doe, RN. Celecoxib 100 mg @ 0800 with applesauce, Jane Doe RN. 1200-Tramadol 50mg PO with OJ for pain rated 6 out of 10. Jane Doe RN.

0800-Amoxicillin 250mg PO with water. J. Doe, RN. When documenting information in a client's health care record, the nurse should sign each entry by name, first initial and last name, and title. Correct documentation also includes recognition of those abbreviations and terms on the "Do Not Use" list such as "per os" and "OJ" which can be confused with other terminology meanings. Time stamps should also be included in documentation.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? 1 Unit of glucose 1 bottle of glucose One U of glucose 1U of glucose

1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking? 1 to 2 months 3 weeks 2 weeks 3 to 4 months

1 to 2 months

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? -Up to 2 weeks -Up to 1 week -1 to 3 days -Up to 24 hours

1 to 3 days The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.

What are the four benefits to the use of an RAI?

1. Residents respond to individualized care. 2. Staff communication becomes more effective. 3. Resident and family involvement increases. 4. Documentation becomes clearer.

According to HIPAA, patients have 5 rights to:

1. See and copy their health record 2. Update health record 3. Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare operations. 4. Request a restriction on certain uses or disclosures 5. Choose how to receive health information

The nurse identifies the correct steps for removal of an NG tube:

1. identify the client 2. raise HOB to 30-45 degrees 3. put on non sterile gloves 4. discontinue suction 5. remove tube while client holds breath

A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb/ 65.7 kg Explanation: A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use? 0815 0945 1945 2015

2015 Military time uses a 24-hour time cycle instead of two 12-hour cycles. So, 8:15 p.m. is equivalent to 2015.

A nurse is caring for an adult client who ate a chicken breast and drank a glass of water. There are 60g of protein in the chicken breast. Calculate the energy intake, in kcalories, for this food.

240

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome? -3 hours -6 hours -9 hours -12 hours

3 hours Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months. Some scientific statements have endorsed its expanded use for up to 4.5 hours.

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method? 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours 4/10 pain on pain scale, epigastric pain; with reports of nausea NPO, 4/10 pain, epigastric pain, nausea 4/10 pain with nausea; on IV fluids

4/10 pain on pain scale, epigastric pain; with reports of nausea Charting by exception charts only that which falls outside the standard of care and norms. 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours is incorrect because the IV fluids and morphine are expected to occur. NPO, 4/10 pain, epigastric pain, nausea is incorrect because NPO is expected. 4/10 pain with nausea; on IV fluids is incorrect because IV fluids are expected.

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4 The patient is weighed to determine the dose of t-PA. Typically two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. Of the calculated dose, 10% is administered as an IV bolus over 1 minute. The remaining dose (90%) is administered IV over 1 hour via an infusion pump. First, the nurse must convert the patient's weight to kilograms (132/2.2 = 60 kg), then multiply 0.9 mg × 60 kg = 54 mg. Next, the nurse figure out that 10% of 54 mg is 5.4 (54 ×.10). The nurse will initially administer 5.4 mgs IV bolus over 1 minute.

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? 7 to 10 days 2 weeks 4 weeks 2 to 3 days

7 to 10 days

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? 300 to 350 mg/dL 150 to 240 mg/dL 80 to 110 mg/dL 250 to 300 mg/dL

80 to 110 mg/dL

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? -A 60-year-old Black man -A 40-year-old White woman -A 62-year-old White woman -A 28-year-old pregnant Black woman

A 60-year-old Black man The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.

The nurse recognizes that which of the following clients is at least risk for perioperative complications? A 65-year-old Caucasian man who has a history of arthritis A 32-year-old African-American woman who takes prednisone A 76-year-old Asian man who takes clopidogrel A 45-year-old African-American man recently diagnosed with type 2 diabetes

A 65-year-old Caucasian man who has a history of arthritis

A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results? A urine creatinine level of 1.2 mg/dL A blood urea nitrogen level of 42 mg/dL A creatine kinase level of 120 U/L A serum creatinine level of 0.9 mg/dL

A blood urea nitrogen level of 42 mg/dL

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A client's diagnosis linked to a disease outbreak A client's Social Security number Information about a client's past health conditions A client's address A deceased client's history for organ donation

A client's Social Security number Information about a client's past health conditions A client's address Client information that is considered confidential includes client names and all identifiers, such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the client is sick or in the hospital, office, or clinic, the assessments and treatments the client receives, and information about past health conditions. Exceptions to confidentiality include disclosure of client information for the purpose of tracking and notification of disease outbreaks and information about a deceased person's organ donation.

What is a Resident Assessment Instrument (RAI/MDS)?

A comprehensive assessment and care planning process used by the nursing home industry since 1990 as a requirement for nursing home participation in the Medicare and Medicaid programs. It provides data for monitoring changes in resident status that are consistent and reliable over time.

The nurse expects informed consent to be obtained for insertion of: An indwelling urinary catheter A gastrostomy tube A nasogastric tube An intravenous catheter

A gastrostomy tube

What is the OASIS?

A group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)

A patient is scheduled to have a heart valve replacement with a porcine valve. Which patient does the nurse understand may refuse the use of any porcine-based product? A patient of Baptist faith A patient of Jewish faith A patient of Lutheran faith A patient of Catholic faith

A patient of Jewish faith

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A recommendation for pain management by the emergency department health care provider who admitted the client a week ago A conversation addressing the need for durable medical equipment when the client goes home

A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A conversation addressing the need for durable medical equipment when the client goes home Care plan conferences are discussions about client care, usually involving several disciplines. Interdisciplinary conferences help to coordinate services so that the client's plan of care can be developed and implemented in the most efficient way. Nurses may initiate these conferences and invite members of the health care team from other departments (e.g., physical therapy, social services, dietary). Clients who most benefit from such conferences are those with multiple, complex problems. The emergency health care provider is no longer needed to address care provided in the health care facility.

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? A safe environment Referral to an ophthalmologist Restrictions of the patient's unassisted mobility activities Probable cataract extractions

A safe environment

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? Restrictions of the patient's unassisted mobility activities A safe environment Probable cataract extractions Referral to an ophthalmologist

A safe environment

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? -A thrombus formation at the site of the endarterectomy -This is a normal occurrence after an endarterectomy and would not be a concern. -Bleeding from the endarterectomy site -Surgical wound infection

A thrombus formation at the site of the endarterectomy Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body.

What is focus charting?

A unique narrative format in that it places less emphasis on patient problems and instead focuses on patient concerns such as a sign or symptom, a condition, behavior, or a significant event.

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A never event A variance An audit A sentinel event

A variance This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply. The nurse uses sign-in sheets that contain information about the reason for the client visit. A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses white boards on an unlimited basis. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. The nurse leaves a detailed appointment reminder message on a client's voice mail.

A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. Examples of incidental disclosures of client health information that are allowed by HIPAA regulations include: a visitor hearing a confidential conversation when the nurses are in appropriate surroundings and using low voices; the use of x-ray light boards that can be seen by a passersby as long as the x-rays are not left unattended by the health care staff; the calling out of names in the waiting room when the reason for the client visit is not disclosed. The following are not allowed by HIPAA regulation: the nurse using a sign-in sheet that contains information about the reason for the visit; the use of white boards on an unlimited basis; the nurse leaving a detailed appointment reminder message on a client's voice mail. It is important that the nurse is aware of HIPAA regulations and common examples of incidental disclosures that are considered allowed in the nurse's work setting.

A provider finds the patient has clear breath sounds at 16 breaths a minute and excludes this from the charting. This is an example of? A. Charting by exception B. PIE Charting C. Inaccurate MRN update D. Exclusion Charting

A. Charting by exception

Which of the following is a common irritant that acts as a trigger of asthma? a) Esophageal reflux b) Molds c) Peanuts d) Aspirin sensitivity

A. Esophageal reflux Esophageal reflux, viral respiratory infections, cigarette smoke, and exercise are all irritants that can trigger asthma. Peanuts, aspirin sensitivity, and molds are antigens

Documentation tools used to efficiently record routine aspects of nursing care are known as? A. Flow Sheets B. Progress Sheet C. PIE Chart D. Expectation Sheet

A. Flow sheet

A commonly prescribed methylxanthine used as a bronchodilator is which of the following? a) Theophylline b) Terbutaline c) Albuteral d) Levalbuteral

A. Theophylline Theophylline is an example of a methylxanthine. All the others are examples of inhaled short-acting beta2 agonists.

What are collaborative pathways?

AKA Critical pathways/care maps used in case management model that specifies the care plan linked to expected outcomes along a timeline.

A trauma patient whose condition is changing rapidly and who requires intensive nurse monitoring and intervention merits a higher rank of attention than a patient whose condition is stable in what kind of record?

Acuity record

The nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next?

Administer pain medication. Explanation: Gastrostomy feeding tubes are uncomfortable for the first days after insertion. The client will tolerate site care better after analgesic administration. While waiting for the medication to take effect, the nurse can prepare the area. After the medication is working, the nurse provides for privacy and begins site care, carefully assessing for other reasons for site pain including excessive erythema or edema.

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? Pituitary Adrenal Thyroid Parathyroid

Adrenal

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. The nurse asks the health care provider to describe the admitting diagnosis of the client. After introductions, the nurse states the client name, room number, and problem. The nurse asks the health care provider to estimate the discharge date for the client. The nurse asks the health care provider to comment on the present situation before giving recommendations. The nurse states that the client's condition "could be life-threatening." The nurse reads back the health care provider's new orders at the conclusion of the call.

After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the health care provider's new orders at the conclusion of the call. The ISBARR format is an effective tool for communication in the health care setting. This template outlines the conversation to occur between the nurse and the health care provider in the question above. The nurse would perform the following actions when using this guide: • after introductions, the nurse would state the client name and other important demographic information regarding the client • the nurse could potentially state that the client's condition "could be life-threatening," • the nurse reads back the health care provider's new orders at the conclusion of the call.The nurse would not ask the health care provider to describe the admitting diagnosis of the client. The nurse would not ask the health care provider to estimate the discharge date for the client. The nurse would not ask the health care provider to comment on the present situation before giving recommendations.

Which term refers to the failure to recognize familiar objects perceived by the senses? -Agnosia -Agraphia -Apraxia -Perseveration

Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Yelling at staff members, dementia worse today, refused breakfast Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients Confused, belligerent, and uncooperative with care

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using terms such as "inappropriate behavior" or "belligerent" is judgmental. The nurse should document only actual behaviors that the nurse witnesses.

In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate? Allow the client to wear dentures. Have the client void. Have client wear hospital gown. Remove all jewelry.

Allow the client to wear dentures.

A client refuses to remove her wedding band when preparing for surgery. What is the bestaction for the nurse to take? Remove the ring once the client is sedated. Discuss the risk for infection caused by wearing the ring. Allow the client to wear the ring and cover it with tape. Notify the surgeon to cancel surgery.

Allow the client to wear the ring and cover it with tape.

Choice Multiple question - Select all answer choices that apply. After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options. a) Increase oxygen distribution b) Decrease alveolar ventilation c) Alter smooth muscle tone d) Reduce airway obstruction

Alter smooth muscle tone • Reduce airway obstruction • Increase oxygen distribution Bronchodilators relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: Some facilities do not require them on their plans of care. Rationales are only important while the nurse is in training. The use of rationales is not commonly practiced in the clinical setting. Although not written, the nurse must know or question the rationale before performing an action. The rationale is deleted to provide additional charting space in the computer system.

Although not written, the nurse must know or question the rationale before performing an action. Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.

A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign? Urethral catheterization An insertion of an intravenous catheter An open reduction of a fracture Irrigation of the external ear canal

An open reduction of a fracture

What is the *Health Information Exchange (HIE)*?

An organization that provides services to enable the electronic sharing of health-related information.

Which is true of collaborative pathways? Are also called critical pathways or care maps Focus on the client's problems, strengths, and needs Incorporate the care plan into the progress notes Only allow recording of significant findings in the notes

Are also called critical pathways or care maps Collaborative pathways—also called critical pathways or care maps—are used in the case management model. The collaborative pathway specifies the care plan linked to expected outcomes along a timeline. With PIE charting, the care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). With focus charting, a focus column is used that incorporates many aspects of a client and client care. The focus may be a client strength, problem, or need. Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? -Dipyridamole -Aspirin -Clopidogrel -Ticlodipine

Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

The nurse has identified the nursing concern of aspiration risk for a client. When preparing to assist this client with eating, how can the nurse best reduce this risk?

Assess the client's level of consciousness. Explanation: Decreased level of consciousness greatly increases a client's risk of aspirating; it is imperative that the nurse assess this prior to the client eating. It is appropriate for the nurse to assess the client's mouth and abdomen and assess for nausea, but none of these actions directly address the client's risk of aspiration.

Prior to allowing a client to eat, which action is most important for the nurse to take?

Assess the client's level of consciousness. Explanation: The most important thing the nurse can do is to ensure the client is alert enough to safely eat without aspirating. Next, ensuring the client is physically able to self-feed and safely swallow is necessary. The client's cultural needs and eyesight are least important.

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? Assess the triggers from the data. Document the findings on an occurrence report. Provide a comprehensive written report to the client ombudsperson. Repeat the minimum data set in 2 weeks.

Assess the triggers from the data. Once the minimum data set is complete, it will identify elements or triggers for issues that the resident either has or is at risk for developing. The information should not be documented on an occurrence report, as it is not is a comprehensive written report required to be sent. There is no need to complete the minimum data set in 2 weeks unless the resident has a significant change in condition.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals. Explanation: There are many reasons a client may refuse food that is served. The nurse should assess for food preferences, when the client generally eats, whether the client has digestive concerns, and cultural beliefs about foods. Leaving the client alone to eat, or simply delegating feeding, does not encourage intake. The client does not need an appetite stimulant until a full assessment has been conducted and other interventions have been implemented.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report the error to the primary provider.

Attach a copy of the incident report to the chart. For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however, stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? -Limited attention span and forgetfulness -Hemiplegia or hemiparesis -Lack of deep tendon reflexes -Auditory agnosia

Auditory agnosia Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%. a) 58 mm Hg; 88% b) 60 mm Hg; 90% c) 56 mm Hg; 86% d) 54 mm Hg; 84%

B. 60 mm Hg; 90% The goal is a PaO2 of at least 60 mm Hg and an SaO2 of 90%.

Which kind of document should concisely summarize the reason for treatment, significant findings, the procedures performed and treatment rendered, the patient's condition on discharge or transfer, and any specific pertinent instructions given to the patient and family. A. Follow-up order B. Discharge summary C. Patient history D. Medical record E. Visit conclusion document

B. Discharge summary

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis

B. Respiratory acidosis In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites. Explanation: With glucose monitoring, blood from the fingertips shows changes in blood glucose more quickly than other testing sites. With signs and symptoms of hypoglycemia, a fingertip site should be used. Calibrate the glucose monitors at least every month. Glucose levels increase with illness and stress to the body.

A nurse is caring for a postoperative patient who has a prescription for morphine 2 mg IV every 3 hours. Which examples documenting pain management best reflect recommended guidelines? Select all that apply. a. 6/12/25 0945 Morphine 2 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN. b. 6/12/25 0950 Morphine 2 mg administered IV. Patient appears to be comfortable. M. Patrick, RN. c. 6/12/25 1015 Administered morphine 2 mg IV at 0945, patient reporting pain as 2 on a scale of 1 to 10. M. Patrick, RN. d. 6/12/25 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/25 0945 Morphine IV 2 mg will be administered to patient every 3 hours. M. Patrick, RN f. 6/12/25 0945 Patient states they do not want pain medication despite return of pain. After discussion, patient agrees to try morphine 2 mg IV. M. Patrick, RN

C, D, F The nurse should enter information in a complete, accurate, concise, current, and factual manner, indicating the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes, derogatory terms, and judgments such as "response to pain appears to be exaggerated" or "seems to be comfortable." Stating that medication will be given does not document care given; this prescription/intervention belongs in the plan of care.

Histamine, a mediator that supports the inflammatory process in asthma, is secreted by a) Neutrophils b) Eosiniphils c) Mast cells d) Lymphocytes

C. Mast cells Mast cells, neutrophils, eosinophils, and lymphocytes play key roles in the inflammation associated with asthma. When activated, mast cells release several chemicals called mediators. One of these chemicals is called histamine.

A patient with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? a) Atrovent b) Combivent c) Proventil d) Flovent

C. Proventil Proventil, a SABA, is given to asthmatic patients for quick relief of symptoms. Atrovent is an anticholinergic. Combivent is a combination SABA/anticholinergic, and Flovent is a corticosteroid

What kind of information format is used to organize entries in the progress notes of the POMR? A. ADPIE B. PIE C. SOAP D. PMAR

C. SOAP

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: a) muffled or distant heart sounds. b) paradoxical chest wall movement with respirations. c) diminished or absent breath sounds on the affected side. d) tracheal deviation to the unaffected side.

C. diminished or absent breath sounds on the affected side. In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? -Stent placement -Removal of the carotid artery -Percutaneous transluminal coronary artery angioplasty -Carotid endarterectomy

Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.

Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)? Centers for Medicare and Medicaid Services The Joint Commission World Health Organization Department of Social Services

Centers for Medicare and Medicaid Services The HITECH Act was established in 2009 to create incentives for professionals and agencies to receive financial payment for the meaningful use of technology to improve client care. The Centers for Medicare and Medicaid Services is the agency responsible for monitoring compliance to HITECH. The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. The World Health Organization is a specialized agency of the United Nations that is concerned with international public health. There is a department of social services in each state that focuses on benefits and facilities such as education, food subsidies, health care, police, fire service, job training and subsidized housing, adoption, community management, policy research, and lobbying.

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? -Large artery thrombosis -Cerebral aneurysm -Cardiogenic emboli -Small artery thrombosis

Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? -Large artery thrombosis -Cerebral aneurysm -Small artery thrombosis -Cardiogenic emboli

Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

A shorthand method of documenting normal findings, based on standardized normals, standards of practice, and predetermined criteria for assessments and interventions is?

Charting by exception (CBE)

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?

Check the medical record for the client's prescribed diet. Explanation: The nurse ensures the client has received the correct meal tray. Often a client on a dysphagia diet will have a special diet that includes softer or pureed foods and thickened liquids that aren't available on the regular diet tray. The other actions are not incorrect, but the client may not be on a chopped food diet. Sometimes the client with dysphagia just requires sips between bites, and there is no reason to use foods from the unit's kitchen area. The best action the nurse can take is to ensure the client get the correct meal tray.

Which nursing action associated with successful tube feedings follows recommended guidelines?

Check the residual before each feeding or every 4 to 6 hours during a continuous feeding. Explanation: The nurse should check the residual before each feeding or every 4 to 6 hours during a continuous feeding. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia. A closed system is the best way to prevent contamination during enteral feedings. The bowel sounds do not have to be assessed as often as 4 times per shift. Once a shift is sufficient. Food dye should not be added as a means to assess tube placement or potential aspiration of fluid.

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following? Cheeseburger, french fries, coleslaw, and ice cream Grilled salmon, rice pilaf, green beans, and cantaloupe Turkey breast, baked sweet potato, asparagus, and an orange Baked chicken, mashed potatoes, broccoli, and strawberries

Cheeseburger, french fries, coleslaw, and ice cream

The nurse recognizes that the client most at risk for mortality associated with surgery is the: Client with controlled hypertension Client who is obese Client with chronic alcoholism Client with controlled diabetes

Client with chronic alcoholism

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? Client's record and occurrence report Occurrence report and critical pathway Critical pathway and care plan Care plan and client's record

Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

Which insult or abnormality can cause an ischemic stroke? -Cocaine use -Arteriovenous malformation -Trauma -Intracerebral aneurysm rupture

Cocaine use Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm rupture are associated with hemorrhagic stroke.

What is the *Electronic Database*?

Collection of data that allows easy searching and easy retrieval of similar pieces of data from many records.

A young adult with cystic fibrosis is admitted to the hospital for aggressive treatment. The nurse first: a) Provides nebulized tobramycin (TOBI) b) Gives oral pancreatic enzymes with meals c) Collects sputum for culture and sensitivity d) Administers vancomycin intravenously

Collects sputum for culture and sensitivity Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

Which statement about client records and documentation is correct? Communication is the primary purpose of client records. Clients should keep the original record at home in a fireproof safe. Nurses should not document progress notes in a client's record. Health care providers will not review nurses' documentation in the client's record.

Communication is the primary purpose of client records. Communication is the primary purpose of client records. Original records are kept by the facility, not the client. Nurses should document key information in the client record, and health care providers review nursing documentation to help make clinical decisions.

*In this PIE chart note, what is the "E"?* - Risk for trauma related to dizziness - Instructed to call for assistance when getting OOB. Call light in reach. - Consistently calls for assistance when getting OOB and continues to experience dizziness (OOB = Out of Bed)

Consistently calls for assistance when getting OOB and continues to experience dizziness

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Passing instruments Setting up the sterile tables

Coordinating the surgical team

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply. Causative Cosmetic Diagnostic Palliative Normative

Cosmetic Diagnostic Palliative

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? Immediately delete the incorrect documentation. Create an addendum with a correction. Contact information technology (IT) staff to make the correction. Contact the health care provider.

Create an addendum with a correction. If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis? a) Impaired swallowing b) Imbalanced nutrition: More than body requirements c) Unilateral neglect d) Anxiety

D. Anxiety In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

An overview of valuable patient information such as documentation, lab and test results, orders, and medications is known as what? A. Hospital visit confirmation B. Procedural information C. Medical Record D. Patient Care Summary E. Result Summary

D. Patient Care Summary

The nurse is assigned the care of a 30-year-old female patient diagnosed with cystic fibrosis (CF). Which of the following nursing interventions will be included in the patient's plan of care? a) Restricting oral intake to 1,000 mL/day b) Discussing palliative care and end-of-life issues with the patient c) Providing the patient with a low sodium diet d) Performing chest physiotherapy as ordered

D. Performing chest physiotherapy as ordered Nursing care includes helping patients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, chest physiotherapy, and breathing exercises. In addition, the nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. The patient with CF also experiences increased salt content in sweat gland secretions; thus, it is important to ensure the patient consumes a diet that is adequate in sodium. As the disease progresses, the patient will develop increasing hypoxemia. In this situation, preferences for end-of-life care should be discussed, documented, and honored; however, there is no indication that the patient terminally ill.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: potassium chloride an acetaminophen suppository dantrolene sodium (Dantrium) verapamil (Isoptin)

Dantrium

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? Unresponsive to verbal or tactile stimuli Yelling and pulling at equipment No movement in right lower leg Denies sensation to perineum and lower abdomen

Denies sensation to perineum and lower abdomen

Who is allowed to give verbal orders?

Directly by a physician or nurse practitioner

______________ is the written or electronic legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating.

Documentation

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply. Documenting entries that have unidentifiable writers' names and titles Documenting entries that are up to date and comprehensive Recording the date and time of all entries Documenting entries that are subjective Using approved agency abbreviations

Documenting entries that are up to date and comprehensive Recording the date and time of all entries Using approved agency abbreviations Recording the date and time of all entries, documenting up-to-date and comprehensive entries, and using agency-approved abbreviations are examples of defensible charting. Documenting entries that have unidentifiable writers' names and titles and entries that are subjective are not in line with the principles of defensible charting, as these could impede clients' safety and continuity of care.

A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?

Drink juice for majority of fluid intake. Explanation: Water should comprise the majority of fluid intake. The remainder should come from food sources such as fruit or 100% fruit juices.

The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room? During the postoperative phase During the transfer phase During the intraoperative phase During the preoperative phase

During the postoperative phase

Which of the following bits of information are protected by HIPAA? A. Patient name and address B. Health history C. Medication list D. A and C E. All of the above F. None of the above

E. All of the above

A nurse makes an error when paper charting, they should: A. Whiteout the error and rewrite the correct information B. Scribble over the error and rewrite the information C. Write "error", and then their initials followed by the correct information D. Dispose of the paper and get a new one E. Draw a line through the incorrect info, write initials and then write the correct info

E. Draw a line through the incorrect info, write initials and then write the correct info

What action by the nurse best encompasses the preoperative phase? Shaving the client using a straight razor Educating clients on signs and symptoms of infection Documenting the application of sequential compression devices (SCDs) Monitoring vital signs every 15 minutes

Educating clients on signs and symptoms of infection

What is the *Electronic Medical Record (EMR)*?

Electronic patient care record created by a facility or facilities having common ownership; the data are not shared between providers in facilities under different ownership (Ex. Sutter vs Kaiser)

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? -Checking stools for occult blood -Performing range-of-motion (ROM) exercises on the left side -Keeping skin clean and dry -Elevating the head of the bed to 30 degrees

Elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

A fractured skull would be classified under which category of surgery based on urgency? Required Urgent Elective Emergent

Emergent

A gunshot wound would be classified under which category of surgery based on urgency? Urgent Elective Required Emergent

Emergent

Informed consent from the surgical client is essential in all of the following categories of surgery except: Elective surgery Urgent surgery Required surgery Emergent surgery

Emergent surgery

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? Ensure that the client's name appears on all pages. Leave spaces between entries and signature. Use abbreviations wherever possible. Record all facts and subjective interpretations.

Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? -Every 15 minutes -Every 30 minutes -Every 45 minutes -Every hour

Every 15 minutes Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

Every 4 to 6 hours Explanation: Checking for residual before each feeding or every 4 to 6 hours during a continuous feeding according to institutional policy is implemented to identify delayed gastric emptying. Residuals are not measured immediately after a flush.

Which charting format permits documentation on any significant topic, not just client problems? CBE SOAP PIE FOCUS

FOCUS FOCUS charting permits documentation on any significant topic. It is organized around data, action, and response. Each of the remaining responses center their documentation on the identification of a problem.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? PIE FOCUS Narrative Exception

FOCUS The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

A form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.is known as a __________ record.

Graphic

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Fentanyl Succinylcholine Halothane Propofol

Halothane

The nurse recognizes the client has reached stage III of general anesthesia when the client: Loss of consciousness Exhibits shallow respirations and a weak, thready pulse Has small pupils that react to light Unable to maintain airway Ability to respond to verbal commands Complains of ringing or buzzing in the ears Exhibits no change in behavior Paralysis of the lower extremities

Has small pupils that react to life

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? Seizures Itching Sore throat Headache

Headache

A patient develops malignant hyperthermia. Which of the following most likely would be the first indicator of this complication? Tentanus-like jaw movements Body temperature rise of 2 degrees F Heart rate over 150 beats per minute Generalized muscle rigidity

Heart rate over 150 beats per minute

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? -Instruct the client to lie on the bed when eating. -Offer liquids frequently and in large quantities. -Help the client sit upright when eating and feed slowly. -Allow optimum physical activity before meals to expedite digestion.

Help the client sit upright when eating and feed slowly. Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? -Nausea, vomiting, and profuse sweating -Hemiplegia, seizures, and decreased level of consciousness -Difficulty breathing or swallowing -Tachycardia, tachypnea, and hypotension

Hemiplegia, seizures, and decreased level of consciousness Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? -Heparin sodium -Dexamethasone -Methyldopa -Phenytoin

Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take?

Hold the enteral nutrition and notify the primary care provider. Explanation: When the residual is greater than 500 mL, the enteral feeding should be held and the primary care provider (PCP) needs to be called for further instructions. If there had been two consecutive residuals >250 mL, the PCP would consider ordering a promotility agent. The PCP will consider decreasing the rate of the tube feeding and may or may not want the residual returned since it is so large. The nurse would not discard or replace the residual and merely chart the amount of the residual and continue the tube feeding at the ordered current rate. The excessive large residuals will increase the client's risk for aspiration.

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: -Obesity -Dyslipidemia -Smoking -Hypertension

Hypertension Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for? Hypertension Glucosuria Hypoglycemia Dehydration

Hypoglycemia

Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will be able to hear the surgeon during the surgery." "I will become unconscious." "I will lose the ability to move my legs." "A needle will deliver the anesthetic into the area around my spinal cord."

I will become unconscious

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "I'm so glad that I will be unconscious during the surgery." "I'll be sleepy but able to respond to your questions." "Only the surgical area will be numb." "I won't feel it, but I'll have a tube to help me breathe."

I'll be sleepy, but able to respond to your questions.

Which stage of anesthesia is referred to as surgical anesthesia? III I II IV

III

A nurse is delivering meal trays to clients on the unit. One client has a fractured dominant arm which is in a sling. What is the first nursing action when bringing the tray into the client's room?

Identify the name of the client. Explanation: When serving meal trays, the nurse first identifies the name of the client to ensure the client receives the correct meal tray. The nurse will then assist this client, who has limited mobility of the arm, in preparing the food by removing lids from the food items, opening cartons of fluids, and cutting food into bite-sized pieces.

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?

If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. Explanation: The nurse would measure the volume and pH of the aspirated fluid, then flush the tube with water. The nurse would not place the client in Trendelenburg position as this could lead to reflux of the feeding from the stomach and possibly cause aspiration of the solution into the lungs. The nurse would not use a small syringe or continue to instill air until fluid is aspirated.

Which statement is not true regarding a medication administration record (MAR)? If the client declines the dose, the nurse does not have to document this on the MAR. The MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR. If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.

A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?

If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. Explanation: If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area.

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?

If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. Explanation: Warm water and gentle pressure should be used to unclog a tube. If a large amount of residue is accidentally aspirated, the health care provider should be notified. If the client is nauseated, the head of the bed should remain elevated and an antiemetic administered as prescribed. The tube should be in the stomach, not the esophagus.

Which are high-risk errors in documentation? Select all that apply. Inadequate admission assessment Failure to document completely Charting in advance Batch charting Falsifying client records

Inadequate admission assessment Failure to document completely Charting in advance Falsifying client records Although batch charting is not ideal, it is not considered a high-risk error made in documentation. High-risk errors include falsifying client records, charting in advance, failure to record changes in a client's condition, failure to document that the health care provider was notified when a client's condition changed, inadequate admission assessment, incomplete documentation, and failure to follow agency standards or policies on documentation.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Incident report Nurse's shift report Transfer report Telemedicine report

Incident report An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

In the EHR, what does the *Clinical Decision Support (CDS)* section do?

Includes academic information, medical logic, and analytic programs built into the EHR that can assist the health care provider make diagnoses and clinical decisions about patient care. Ex. Genetic information, past patient health history data that influences current health problem, potential drug-drug interactions, etc.

The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate?

Increase the client's fluid intake. Explanation: Dehydration can cause increases in hematocrit, BUN, and creatinine. Calorie restriction, increased protein intake, and TPN are not indicated by these laboratory data.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? -Decreased level of consciousness (LOC) -Elevated blood pressure -Increased urine output -Decreased heart rate

Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.

Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

*In this PIE chart note, what is the "I"?* - Risk for trauma related to dizziness - Instructed to call for assistance when getting OOB. Call light in reach. - Consistently calls for assistance when getting OOB and continues to experience dizziness (OOB = Out of Bed)

Instructed to call for assistance when getting OOB. Call light in reach.

A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding?

Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. Explanation: Intermittent feedings are delivered at regular intervals, using gravity for instillation or a feeding pump to administer the formula over a set period of time. The steps for administering feedings are similar regardless of the tube used. Intermittent feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeding intolerance is less likely to occur with smaller volumes. Feeds are not warmed prior to instillation.

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

Iodine Explanation: A chronic deficiency of iodine can lead to endemic goiter. The major initial symptom is an enlarged thyroid gland.

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition?

Iodine Explanation: A chronic deficiency of iodine can lead to goiter, which manifests as an enlargement of the thyroid gland.

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? -Ischemic -Hemorrhagic -Right-sided -Left-sided

Ischemic Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.

As a circulating nurse, what task are you solely responsible for? Estimating the client's blood loss. Handing instruments to the surgeon. Counting sponges and needles. Keeping records.

Keeping records.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? -Positioning the client to prevent airway obstruction -Keeping the client in one position to decrease bleeding -Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess -Maintaining the client in a quiet environment

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? -Limited attention span and forgetfulness -Visual agnosia -Lack of deep tendon reflexes -Auditory agnosia

Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? -Transient ischemic attack (TIA) -Left-sided cerebrovascular accident (CVA) -Right-sided cerebrovascular accident (CVA) -Completed Stroke

Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? -Limited attention span and forgetfulness -Hemiplegia or hemiparesis -Lack of deep tendon reflexes -Visual and auditory agnosia

Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? -Diphenhydramine (Benadryl) -Lioresal (Baclofen) -Heparin -Pregabalin (Lyrica)

Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in? Prone position Trendelenburg Lithotomy position Left lateral Sim's

Lithotomy

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? -Elevating the head of the bed to 30 degrees -Monitoring for seizure activity -Administering a stool softener -Maintaining a patent airway

Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? Shoe covers are used. Hair is pulled back and covered by a cap. Scrub top and drawstring are tucked into pants. Mask is placed over nose and extends to bottom lip.

Mask is placed over nose and extends to bottom lip

The nurse is conducting a health history of a preoperative client. The client shares that she experienced vaginal itching and burning and labial swelling after her partner tried a new brand of condoms. The nurse suspects that the client: Is susceptible to the lubricant. Needs to change her position during intercourse. May have a sexually transmitted disease. May have a latex allergy.

May have a latex allergy.

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client? Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered. The client's pain should be documented on a scale of 0 to 10 when documenting the administration of pain medication. Medication that is not administered should be documented along with the reason. Steps taken to encourage the client to comply should be documented along with assessment findings.

Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered. Accurate and timely documentation prevents medication from being administered too frequently or withheld unnecessarily. Therefore, it is most appropriate to document that the pain medication was given immediately following administration. However, in circumstances where medication cannot be given or the client refuses medication, this information should be documented with detailed information about the reason. While assessing the client's pain management is important, it is not the culminating factor to administer prescribed medication or in documenting the actual administration. While it is important to encourage clients to take the medication, if a client refuses pain medication steps taken to encourage the client to comply is not an intervention for documenting administration.

What should the nurse consider when teaching a man with well-defined muscle mass about meal planning?

Men have a higher need for proteins. Explanation: Due to the higher percentage in muscle mass in men, they have a higher need for proteins in their diet. Men do not have a higher or lower need for carbohydrates, minerals, or vitamins.

SOAP Note:

Method of charting commonly used in ambulatory care (subjective, objective, assessment, plan)

A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? -Cluster headaches can cause severe debilitating pain. -Migraines often coincide with menstrual cycle. -Tension headaches are easier to treat. -Headaches are the most common type of reported pain.

Migraines often coincide with menstrual cycle. Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.

*Which component of the RAI?* A core set of screening, clinical, and functional status elements that form the foundation of the comprehensive assessment of all residents in long-term care facilities certified to participate in Medicare or Medicaid. The items in the minimum data set standardize communication about resident problems and condition.

Minimum data set

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report? Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. MR#12345, Alfred Jones, 76-year-old male 8 days post-op for RVEF. Transferring for monitoring for the next week. Braden score 13 and vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/

Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. The nurse should include the current assessment of the client in the verbal handoff summary because it enables the receiving nurse to prepare for the client before arrival. It also allows the receiving nurse to clarify any information that may appear on the written handoff form. Additionally, the nurse should also report the presence of any intravenous fluids and the presence of advanced directives. It is not important to mention the client's medical record number during the communication. Information about intake for the previous meal would only be important if these were directly influencing the client's current status.

Notes written by nurses in a source-oriented record that address routine care, patient data, and patient problems identified in the care plan and include a description of the status of the problem, related nursing interventions, patient responses to interventions, and needed revisions to the care plan are called?

Narrative notes

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? -Report of headache off and on for past month -No bowel movement since yesterday -Nausea -Frequent voiding

Nausea Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Report of headache for past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent?

New foods should be introduced one at a time for a period of 2 to 3 days. Explanation: Solid foods are generally introduced between 4 and 6 months of age. New foods should be introduced one at a time for a period of 2 to 3 days so that any allergic reaction can be identified. Iron-fortified foods are recommended.

The following statement is a message left on a patient's voicemail, state whether or not this is a HIPAA Violation: *"Hi Mr. Smith, this is Jane calling from Dr. Johnson's office. Just wanted to call and confirm your appointment coming up with us. If you are able to, please give us a callback at 123-456-7890, we will be open today until 5pm. Thank you!"*

No, as it does not disclose patient information or allude to the reason for visit

Verify if the following record of a verbal order is written correctly: Patient: Doe, John DOB: 1/2/1967 MRN: 0123456 "Order: Start IV Nitro drip @ 20 mcg/min and titrate for chest pain relief. VO from Dr. Kevin Jacobs - Jessica Gomez RN."

No, it is missing the date and time of issue

Which of the following is the initial diagnostic in suspected stroke? -Noncontrast computed tomography (CT) -CT with contrast -Magnetic resonance imaging (MRI) -Cerebral angiography

Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse? Document the findings and continue moving the client through the preoperative phase. Wait 1 hour and complete the assessment again. Notify the primary physician about the assessment findings. Notify the surgeon to possibly delay the surgery.

Notify the surgeon to possibly delay the surgery.

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action? Give the client plenty of water to aid digestion. Notify the surgeon. Document what foods the client ate. Cancel the surgery.

Notify the surgeon.

During the preoperative assessment, the client mentions allergies to avocados, bananas, and hydrocodone. What is the priority action by the nurse? Notify the dietary department. Notify the nurse manager to follow up on the procedure. Notify the surgical team to remove all latex-based items. Notify the physician regarding postoperative pain medications.

Notify the surgical team to remove all latex-based items.

A nursing unit with patients with higher acuity rankings requires more *what* in comparison to a unit with the same number of patients who have lower acuity ranks.

Nurses

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Making the names of clients on charts visible to the public

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

The nurse is preparing to call a health care provider to report a significant decrease in a client's oxygen saturation level. What action should the nurse take first? Obtain all needed information to give report. Document all findings in the electronic health record. Report the change to the health care provider using ISBAR. Request another nurse stay with the client while the report is called.

Obtain all needed information to give report. The nurse should obtain all needed information first before calling the health care provider, and use the ISBAR format. The nurse will need to document all the findings in the client's record, but should contact the health care provider before documenting due to the significant change in oxygen levels. Asking another nurse to stay with the client is appropriate, but only after all information is gathered.

A woman gets an appendectomy and a few days later notices that her suture site is infected. She returns to the doctors office for it to be assessed. What kind of charting will the nurse use in this sense?

Occurrence charting as infection is a complication and not a normal or expected occurrence during recovery.

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults? Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. All older people face similar risks when undergoing surgeries. Aging processes reduce the chances that surgery will be successful for these clients. Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults.

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position? On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle On his side, with his uppermost leg adducted and flexed at the knee Flat on his back with his arms next to his sides On his back, with his legs and thighs flexed at right angles

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle.

Fentanyl is categorized as which type of intravenous anesthetic agent? Dissociative agent Neuroleptanalgesic Tranquilizer Opioid

Opioid

A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications? Pregnancy Diabetes Urinary tract infection Osteoporosis

Osteoporosis

What is the *Electronic Health Record (EHR)*?

Patient care record created when facilities under different ownership share their data. The goal is for this sharing to be nationwide, creating a situation in which a person's health care record is accessible by designated health care providers anywhere in the nation. The patient will decide which portions of a record will be available to whom.

What is a compilation of the patient's health information (PHI) known as?

Patient record

What is a *Personal Health Record (PHR)*?

Patient records of their own medical data and health history; can be interfaced with applications within EHRs and are used by most large facilities

Regarding the surgical client, which phase refers to the period of time that spans the entire surgical experience? Preoperative Intraoperative Postoperative Perioperative

Perioperative

A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition?

Peripheral parenteral nutrition Explanation: The client requires peripheral parenteral nutrition. Peripheral parenteral nutrition provides temporary nutritional support of approximately 2000 to 2500 calories daily. It can meet a client's metabolic needs when oral intake is interrupted for 7 to 10 days, or it can be used as a supplement during a transitional period as a client begins to resume eating. Total parenteral nutrition (TPN) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Metabolizing nutrition is a way to replenish and supply water to the body. A nasogastric feed is administered through narrow tubing that is inserted through the client's nose into the stomach.

The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury? Peripheral pulses palpable Pulse oximetry 98% Absence of itching Vital signs within normal limits for client

Peripheral pulses palpable (less of a risk for pressure ulcers)

The nurse recognizes that written informed consent is required for insertion of a(n): Oral airway. Urinary catheter. Nasogastric tube. Peripherally-inserted central catheter.

Peripherally-inserted central catheter.

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record? Scribble through the entry. Obtain white-out to cover the entry. Write over the entry in another color pen. Place one line through the entry and initial it.

Place one line through the entry and initial it. The appropriate action is to place one line through the entry and initial it. Any written documentation that cannot be clearly read, or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense.

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? -Assisting the client with meals -Placing food on the affected side of the mouth -Testing the gag reflex before offering food or fluids -Allowing ample time to eat

Placing food on the affected side of the mouth Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery? Knowledge of surgical procedure Types of postoperative pain medication Effective coughing and deep breathing Post-discharge diet

Post-discharge diet

Which principle should guide the nurse's documentation of entries on the client's health care record? Correcting fluid is used rather than erasing errors. Documentation does not include photographs. Precise measurements should be used rather than approximations. Nurses should not refer to the names of health care providers.

Precise measurements should be used rather than approximations. Precise measurements and times must be used whenever possible. It is appropriate to use the names of health care providers and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

The scrub nurse is responsible for: Monitoring the administration of the anesthesia Monitoring the operating-room personnel for breaks in sterile technique Calling the "time-out" to verify the surgical site and procedure Preparing the sterile instruments for the surgical procedure

Preparing the sterile instruments for the surgical procedure.

PIE Chart:

Problem, intervention, evaluation

What kind of medical record is organized around a patient's problems rather than around sources of information and includes the defined database, problem list, care plans, and progress notes.

Problem-oriented medical record (POMR)

Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes are called?

Progress notes

What does the case management model do?

Promotes collaboration, communication, and teamwork among caregivers; makes efficient use of time; and increases quality by focusing care on carefully developed outcomes

The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client?

Psychological reasons for overeating should be explored, such as eating as a release for boredom. Explanation: The nurse would need to take into consideration that psychological reasons for overeating should be explored. One pound of body fat is equal to approximately 3,500 calories. To lose 1 pound/week, the daily intake should be decreased by 500 calories per day. Obesity can be difficult to treat due to various factors.

A ___________ must be completed for residents of Medicare skilled nursing facilities or Medicaid nursing facilities, hospice residents, and short-term stay or respite residents who reside in a facility for longer than 14 days.

RAI

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

RDA level Explanation: The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group.

A 2yo child with specialized nutritional needs is receiving care in the home. The plan of care includes provision of enteral nutrition through a G-tube every 3 hours. For each nursing intervention, specify the associated rationale. Nursing Interventions: 1. Measure the length of the external tube. 2. Elevate the HOB at least 30 degrees. 3. Confirm pH of aspirate is less than 5.5. 4. Replace all gastric contents following measurement of aspirate.

Rationales: 1. reduces the risk of aspiration reduces the risk of bloating helps prevent blockage 2. facilitates the flow of feeding to the gut 3. useful in verifying correct placement 4. prevents electrolyte imbalance

When registered personel are given a verbal order, what should they do to ensure clarity?

Read back

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply. Readable Thoughtful Timely Clear, concise, and complete Accurate, relevant, and lengthy Retrievable on a temporary basis

Readable Thoughtful Timely Clear, concise, and complete Characteristics of effective documentation include accessible, accurate, relevant, consistent, auditable, clear, concise (not lengthy), complete, legible/readable, thoughtful, timely, contemporaneous, sequential, and retrievable on a permanent (not temporary) basis.

In SBAR, what does R stand for? Reinforcing data Response Recommendations Report

Recommendations SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

What is an acuity record?

Record that rank patients as high-to-low acuity in relation to both the patient's condition and need for nursing assistance or intervention.

The person who receives the VO (verbal order) will document it in the patients chart in what way after verifying via read back?

Record the order with the initial VO, write the date and time of issue, issuer's name and title.

What is the *Medication Administration Record (MAR)*?

Record used to electronically track and record administration of patient medications; includes the patient's name, and each medication's name, dose, frequency, and route.

When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings? Call the health department. Clean up the house. Move the client to an assisted living facility. Refer to the health care provider.

Refer to the health care provider. Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. The nurse would refer the client to a health care provider for treatment of depression. Calling the health department or cleaning up the house will not help with the client's depression. Moving the client to an assisted living facility may not be necessary if the client receives treatment for the depression.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? Remind the UAP about the client's right to privacy. Report the UAP to the nurse manager. Notify the client relations department about the breach of privacy. Document the UAP's conversation.

Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? -Leg exercises to strengthen muscle weakness. -Need for support group due to decreased self image related to restricted mobility. -Remove throw rugs and electrical cords from home environment. -Use of tripod cane.

Remove throw rugs and electrical cords from home environment. Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Return to work after taking antibiotics for 24 hours. Ensure the infection is covered with a dressing. Report the infection to an immediate supervisor. Request a role change to circulating nurse.

Report the infection to an immediate supervisor

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Dialogue Documentation Reporting Verification

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

*Which component of the RAI?* Structured, problem-oriented frameworks for organizing minimum data set information and examining additional clinically relevant information about a resident. Resident assessment protocols help identify social, medical, nursing, and psychological problems and form the basis for individualized care planning.

Resident assessment protocols

The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse anticipate observing for the blood gas results related to hyperventilation for this patient?

Respiratory alkalosis (low PaCO2) is the most common finding in patients with an ongoing asthma exacerbation and is due to hyperventilatio

Which information would the nurse be unable to locate in the client care summary or Kardex? Code status Respiratory assessment Activity status IV therapy

Respiratory assessment Information commonly found in a the client care summary or Kardex includes demographic data, code status, safety precautions, basic care needs (such as activity status or diet), and treatment (such as vital sign schedule, IV therapy, and diagnostic or laboratory tests). An assessment would be located on a flow sheet or within the client's medical record.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? -Restrict fluids before surgery. -Administer prescribed medications. -Administer preoperative sedation. -Administer an osmotic diuretic.

Restrict fluids before surgery. Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Review the hospital's process for allowing clients to view their health care records. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out? Ensure that sufficient surgical supplies are available. Review the scheduled procedure, site, and client. Confirm that informed consent has been obtained. Check that all surgical personnel are properly attired.

Review the scheduled procedure, site, and client.

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 Choosing the charting format that the nurse prefers Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting Checking that clients' names are not identified within the chart forms

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 The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take? Review the nursing care plan. Implement changes in the current interventions. Involve the family in changes. Revise the plan of care.

Revise the plan of care. A plan of care should be generated at admission and reviewed regularly. The care plan must be revised to reflect changes in the client's condition. Changes in the care plan will then reflect new interventions to address those changes. The family will not be directly involved in any changes in nursing care.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: -Spatial-perceptual deficits. -Left visual field deficit. -Right-sided paralysis. -Impulsive behavior.

Right-sided paralysis. A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge. Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation.

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The health care provider, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? FOCUS charting narrative charting PIE charting SOAP charting

SOAP charting In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? -Supine -High-Fowler's -Prone -Semi-Fowler's

Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition?

Serum albumin Explanation: Serum albumin levels can help measure protein levels in the body and are good indicators for nutrition status. Hemoglobin levels maintain red blood cells that carry oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs. Creatinine is a laboratory value that assesses kidney function. Oxygen saturation is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood. It is best used to determine how well a client is oxygenating.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: -Weakness on one side of the body and difficulty with speech -Severe headache and early change in level of consciousness -Foot drop and external hip rotation -Confusion or change in mental status

Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office Writing the hemoccult result on a piece of paper and leaving it at the desk Placing a note on the computer terminal with the client's name and information

Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office Reporting to the primary care provider can occur face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax. Placing a note on a computer terminal with client information or writing the hemoccult results on a piece of paper and leaving it at the desk is a violation of the Health Insurance Portability and Accountability Act because the information is visible and accessible to anyone passing by. The other answers are appropriate ways to communicate client information to a health care provider while protecting the client's confidentiality.

A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?

Small intestine Explanation: Most absorption of digested food and minerals occurs in the small intestines. The stomach is responsible for storing food, secreting digestive enzymes, and digestion. The large intestine forms feces and absorbs water to regulate the consistency of stool. The digestive function of the liver is the production of bile.

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? -Thyroid disease -Social drinking -Advanced age -Smoking

Smoking Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

Which is indicative of a right hemisphere stroke -Aphasia -Spatial-perceptual deficits -Slow, cautious behavior -Altered intellectual ability

Spatial-perceptual deficits Clients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemisphere damage causes aphasia; slow, cautious behavior; and altered intellectual ability.

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? Deep breathing and coughing exercises should be completed every 8 hours. Pain medication should be taken before completing deep breathing and coughing exercises. Deep breathing and coughing exercises may be used as relaxation techniques. Splint the incision site using a pillow during deep breathing and coughing exercises.

Splint the incision site using a pillow during deep breathing and coughing exercises.

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage III: surgical anesthesia Stage IV: medullary depression Stage I: beginning anesthesia Stage II: excitement

Stage 2: excitement

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? I III II IV

Stage II

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage I Stage III Stage II Stage IV

Stage IV

A client is receiving continuous tube feeding via a nasogastric (NG) tube. What should the nurse use to determine that the NG is in correct placement? Select all that apply.

Stop tube feedings for 1 hour after medication before testing the pH of the gastric fluid. Visually assess aspirate that it differs from the color and consistency of the tube feeding. Measure the exposed length of feeding tube and compare it to the baseline measurement. Explanation: The tube feeding and medications can alter the pH, so stop the tube feeding for 1 hour before testing the pH of the aspirate. The aspirate from the stomach should be different from the tube feeding: green with particles of off-white or brown may be present and the aspirate should be clear in consistency. The feeding tube has radiographic markings and the same marking present at the nare should be the same as charted in the baseline when the tube was confirmed initially by chest x-ray. Chest x-rays are not repeated to confirm placement of a feeding tube because they would expose the client to unnecessary radiation. The aspirate in the stomach should have a pH range of 4 to 6, and is usually <5.5.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Subjective data should be included when documenting. Objective data are what the client states about the problem. The plan includes interventions, evaluation, and response. Abnormal laboratory values are common items that are documented.

Subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.

SOAPIER stands for?

Subjective, objective, assessment, plan, intervention, evaluation, revision

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Disclosing client health information for research purposes after obtaining permission from the client's health care provider Releasing the client's entire health record when only portions of the information are needed Submitting a written notice to all clients identifying the uses and disclosures of their health information Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

Submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the health care provider's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

The client vomits during the surgical procedure. The best action by the nurse is: Increase the IV infusion rate to compensate for lost fluids. Lower the head of the operating table to promote circulation to the brain. Suction the client to remove saliva and gastric secretions. Administer an anti-emetic to alleviate nausea.

Suction the client to remove saliva and gastric secretions

Which of the following techniques least exhibits surgical asepsis? Suctioning the nasopharyngeal cavity of a client Adding only sterile items to a sterile field Keeping sterile gloved hands above the waist Placing the sterile field at least one foot away from personnel

Suctioning the nasopharangeal cavity of a client.

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern? Surgeon Registered nurse first assistant Anesthesiologist Circulating nurse

Surgeon

Cystic fibrosis (CF) is diagnosed by clinical signs and symptoms in addition to which one of the following tests? a) Sweat chloride concentration b) Arterial blood gases (ABGs) c) Lumbar puncture d) Pulmonary function studies

Sweat chloride concentration Diagnosis of CF is based on an elevated sweat chloride concentration, together with clinical signs and symptoms consistent with the disease.

The nurse is caring for a patient who is at risk for malignant hyperthermia subsequent to general anesthesia. What is the most common early sign that the nurse should assess for? Muscle rigidity ("tetanylike" movements) Hypertension Oliguria Tachycardia

Tachycardia

Which clinical manifestation is often the earliest sign of malignant hyperthermia? Elevated temperature Hypotension Tachycardia (heart rate >150 beats per minute) Oliguria

Tachycardia (>150 beats per minute)

For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway? a) Teaching the client how to perform controlled coughing b) Enforcing absolute bed rest c) Administering ordered sedatives regularly and in large amounts d) Restricting fluid intake to 1,000 ml/day

Teaching the client how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? The 72-year-old client who takes no routine medications. The 28-year-old client who occasionally smoked marijuana in high school. The 35-year-old client with non-insulin dependent diabetes. The 47-year-old client who stopped smoking 2 years ago.

The 35-year-old client with non-insulin dependent diabetes.

Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? The 72-year-old client who takes no routine medications. The 47-year-old client who stopped smoking 2 years ago. The 28-year-old client who occasionally smoked marijuana in high school. The 35-year-old client with non-insulin dependent diabetes.

The 35-year-old client with non-insulin dependent diabetes.

Which statement regarding FOCUS charting is most accurate? The charting focuses on client strengths, problems, or needs. The charting focuses on the injury or illness only. Problem, intervention, evaluation (PIE) charting is used with FOCUS charting. Each note should include each section of the data, action, response (DAR) format of charting.

The charting focuses on client strengths, problems, or needs. FOCUS charting focuses on client strengths, problems, or needs. The injury or illness is not the only focus of this form of charting. PIE charting is separate from FOCUS charting. When using the DAR format, not every area needs to be addressed with each entry.

A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed? The client exhales forcefully with a short expiration. The client breathes in deeply through the nose and mouth. The client places the hands on the lower chest to feel the rise and fall with breathing. The client performs diaphragmatic breathing in a semi-Fowler's position.

The client exhales forcefully with a short expiration.

A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. In what scenario is this most important? The client has had a sudden change in status needing immediate attention. The client is receiving ongoing medication therapy for a chronic disease. The client has enacted his or her rights and demanded to see all records and documentation as they occur. The client is being discharged and the nurse is providing discharge education.

The client has had a sudden change in status needing immediate attention. Computerized charting, which means documenting client information electronically, is most useful for nurses when a terminal is available at the point of care or bedside. These point-of-care (POC) systems allow for timely documentation that can be shared with multiple people and can reduce errors. This is extremely important and beneficial when a client's status has changed and frequent assessments are needed. While the POC system is efficient and can be used when administering medication or documenting discharge instruction, these are not the most probable cause for the suggestion from the provider. The client does have a right to review his or her medical records, but this would not be a reason to document in the POC system.

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply. The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." The client seems depressed. The client is suicidal. The client is in a bad mood.

The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." When documenting observations of client behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. For example, the nurse should not describe the client as depressed or angry. The nurse should document any statements made directly by the client.

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? The client is receiving sufficient relief from pain medication, stating no pain in either knee. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client reports that on a scale of 0 to 10, the current pain is a 3. The client appears to have a low tolerance for pain and frequently reports intense pain.

The client reports that on a scale of 0 to 10, the current pain is a 3. The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

The following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client reports waking up this morning with a severe headache. The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning.

The client reports waking up this morning with a severe headache. The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply. The client's blood pressure trend over the past 24 hours. The primary reason the client was admitted to the hospital. Objective and subjective data from the most recent assessment. An explanation of what is needed to improve the hypotensive state. A history of chronic health conditions affecting the client's family. A review of the full client Kardex with the health care provider.

The client's blood pressure trend over the past 24 hours. The primary reason the client was admitted to the hospital. Objective and subjective data from the most recent assessment. An explanation of what is needed to improve the hypotensive state. When notifying the health care provider about a change in a client's condition, the nurse documents in the client's record the information reported and the instructions received. In an effort to support The Joint Commission's National Patient Safety Goals regarding the improvement of staff communication and identifying client safety risks, the SBAR format has been recommended as a model for effective communication. The SBAR includes: (1) S (Situation): What is the situation about which you are calling? (2) B (Background): Pertinent background information related to the situation; (3) A (Assessment): What is your assessment of the situation? (4) R (Recommendation): Explain what is needed or wanted. For the client who has a change in the vital signs, such as low blood pressure, that change is a sign that there is a problem that warrants an intervention. To be most efficient with the client report, the nurse will include the situation, which includes the current blood pressure reading and a trend over the past day to highlight the change is significant. The nurse will include the background, which is the main reason the client was admitted to the hospital. This information provides some context as to why the current problem may be occurring. The nurse's assessment report will include both objective data (that which can be quantified) and subjective data (which is the nurse's observation of signs and symptoms that cannot be measured). The nurse's report will also include a brief statement about what might be needed to respond to the problem being reported. In some cases, the

In developing the plan of care for the intraoperative client, the nurse recognizes that it is essential to consider: the wishes of the client's family the surgeon's skill in performing the procedure the schedule of the operating room the client's cultural beliefs

The client's cultural beliefs

Which information should the nurse include in a client's plan of care? Select all that apply. The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders The client care assignment of the nursing and support staff The minutes of the most current team conference meetings

The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders The nurse should include the client's problems, goals, and nursing orders; routine care; level of activity; and current medical orders in the client's plan of care, as this information contributes to the nursing care plan. The nurse should not include client care assignment of the nursing and support staff in the client's care plan, as this information is not specific to one client. The nurse should not include minutes from the team conference meetings, as team conferences involve discussing client care problems among selected staff members.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply. The content reflects client needs. The content includes descriptions of situations that are out of the ordinary. The content is not in accordance with professional standards. There are lines between the entries. The documentation is not countersigned. Dates and times of entries are omitted.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted. Incomplete and incorrect documentation by the nurse can potentially increase the nurse's risk for legal problems. The following documentation errors may potentially increase the nurse's risk for legal problems: the content is not in accordance with professional standards; dates and times of entries are omitted. The following documentation would not increase the nurse's risk for legal problems: the content reflects client needs; the content includes descriptions of situations that are out of the ordinary; the documentation is not countersigned.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? -The day before the patient is discharged -After the patient has passed the acute phase of the stroke -After the nurse has received the discharge orders -The day the patient has the stroke

The day the patient has the stroke Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? The edges of a sterile package, once opened, are considered unsterile. If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. Circulating nurses may come in contact with the sterile field without contaminating it. A distance of 3 feet must be maintained when moving around a sterile field.

The edges of a sterile package, once opened, are considered unsterile

The nurse is reviewing a client's chart. When reading the history, physical, and health care provider progress notes, the nurse anticipates finding which information? The health care provider's assessment and treatment Results of laboratory and diagnostic studies Nursing documentation and plan of care Information from other members of the health care team

The health care provider's assessment and treatment The medical history, physical examination, and progress notes record the findings of health care providers as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment. The laboratory results will be in a different section of the health record and not typically in the medical history and treatment plan. Nursing documentation will be in the nursing section. Information from the other members of the health care team is found in the progress notes.

A nurse receives a phone call from a patient's spouse who is requesting a status report on how the patient is doing. What is risky about this situation? *Caller*: "Hi Nurse! This is Mr. Johnson, Lisa's husband. How did the procedure go?"

The identity of the caller cannot be confirmed, the patient may not want anyone to know how they are doing, and there is a risk for a HIPAA violation.

- The patient is homebound and still needs skilled nursing care. - Rehabilitation potential is good. - The patient's status is not stabilized. - The patient is dying. - The patient is making progress in expected outcomes of care. These are all progress summaries that help to determine what in home health documentation with third-party payers (Medicare)?

The need for continuing home care with continued reimbursement for necessary services.

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate?

The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration. A client with COPD typically has a barrel chest in which the anteroposterior diameter is larger than the transverse chest diameter. A client with COPD usually has a respiratory rate greater than 12 breaths/minute and an oxygen saturation rate below 93%.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can accept verbal orders to provide immediate care and record once the client is stable. The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The client must be stabilized before the nurse can obtain any orders from the provider.

The nurse can accept verbal orders to provide immediate care and record once the client is stable. In most agencies, the only circumstance in which the attending health care provider, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the health care provider/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Health care provider can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? The nurse could be fined or even go to jail for violating HIPAA. No action will be taken as long as the parents don't find out. There will be no repercussions if the nurse takes the photo down from the social media page. The nurse could be fired but would not face criminal charges or jail time.

The nurse could be fined or even go to jail for violating HIPAA. The nurse has committed a HIPAA violation and most likely breached the facility's social media policy. The nurse has placed a newborn and family at risk by posting photos to a social media website where anyone is at liberty to view the page. The nurse may well be dismissed for this infraction and is at risk for fines and imprisonment for a HIPAA violation, even if the nurse takes the photo down and the parents do not find out. The managers at the facility should enforce the social media policy, explain violations and consequences to all staff, and have them sign the social media policy.

Which example may illustrate a breach of confidentiality and security of client information? The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse provides information to a professional caregiver involved in the care of the client. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.) The patient talks incessantly. The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient informs the nurse of problems with postoperative nausea in the past and that it was a bad experience. The patient tells the nurse of concerns with the outcome of the procedure.

The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.

When does the nurse understand the patient is knowledgeable about the impending surgical procedure? The patient expresses concern about postoperative pain. The patient discusses stress factors causing the patient to feel depressed. The patient participates willingly in the preoperative preparation. The patient verbalizes fears to family.

The patient participates willingly in the preoperative preparation.

In the EHR, what is the *Computerized Provider Order Entry (CPOE)*?

The section of the EHR for the orders written by the health care provider that are deemed necessary for the patient such as required lab tests, procedures, medications, and treatments.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply. The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. "I feel something is going on the client isn't telling me." The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

A client is prescribed methylprednisolone (Solu-Medrol) 125 mg intravenously. The medication is available in a 125 mg single-dose vial containing 2 mL. The nurse will administer methylprednisolone over 2 minutes. How many mL will the nurse administer each 15 seconds? Write your answer to 2 decimal places. Starting with 0., enter the correct number ONLY.

The volume to be infused is 2 mL over 2 minutes. There are 60 seconds in each minute. For every 15 seconds, the nurse will administer 0.25 mL. 2 mL/120 sec = x/15 sec. 0.25 mL = x

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? -Three hours -One hour -Two hours -Six hours

Three hours Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

The nurse is educating clients who require surgery for various ailments about the perioperative experience. What education provided by the nurse is most appropriate? Intraoperative techniques used to perform the surgery Expected pain levels and narcotic medications used to treat the pain Risks and benefits of the surgical procedures Three phases of surgery and safety measures for each phase

Three phases of surgery and safety measures for each phase

Which are purposes of documentation in health care records? Select all that apply. To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research To provide personal communication to the family

To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research Documentation provides data to facilitate quality, serve as a financial record, assist with clinical research, and support decision analysis. Documentation does not serve to provide personal communication to the family.

A health care provider orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?

Total parenteral nutrition (TPN) Explanation: TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein. PPN is nutritional therapy used for clients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. A PEG is a surgically placed gastrostomy tube. A PEJ is a surgically placed jejunostomy tube.

Sudden withdrawal of which of the following may result in seizures? Steroids Thiazide diuretics Monoamine-oxidase inhibitors Tranquilizers

Tranquilizers

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? -Transient ischemic attack -Cerebral aneurysm -Right-sided stroke -Left-sided stroke

Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

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? Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it. Translators may need additional explanations of medical terms.

Translators may need additional explanations of medical terms. When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.

*Which component of the RAI?* Specific resident responses for one or a combination of minimum data set elements that identify residents who either have or are at risk for developing specific functional problems and who require further evaluation using resident assessment protocols.

Triggers

*True or False?:* Electronic health records help reduce medical errors and adverse events

True

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change?

Try eating foods that are attractive and at the proper temperature. Explanation: The nurse should suggest eating foods that are attractive and at the proper temperature. Other suggestions include eating one food at a time rather than mixing foods and eating foods with different textures and aromas. The nurse should refrain from suggesting spicy foods, which may not be well tolerated by a client or may not be part of the client's flavor profile.

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?

Try to ensure that the client's food is attractive and sufficiently warm. Explanation: Food in the health care setting can often be unattractive and cool. Ensuring that it is appealing to the eyes and presented at the correct temperature can stimulate the client's appetite. Meals should be small and more frequent, not less frequent and larger. Supplements may be nutritionally necessary, but these do not act to increase the client's appetite.

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? Placement of gastrostomy tube A face-lift Tumor excision A biopsy

Tumor excision

A nurse is working with the case management model and using a collaborative pathway. The nurse notes that the client has not met an expected outcome and documents this using occurrence charting. When completing this documentation, what information would the nurse include? Select all that apply. Unexpected event Cause of the event Actions taken in response to the event Goals Incident report recording

Unexpected event Cause of the event Actions taken in response to the event When a client fails to meet an expected outcome or a planned intervention is not implemented in the case management model, this variance from the plan is documented. The usual format for occurrence charting or variance charting is the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate. Goals and an incident report would not be documented in occurrence charting.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure? Up to 4 hours before surgery Up to 2 hours before surgery Up to 6 hours before surgery Up to 8 hours before surgery

Up to 2 hours before surgery

A new graduate is working at a first job. Which statement is most important for the new nurse to follow? Use abbreviations approved by the facility. Document lengthy entries using complete sentences. Use PIE charting, even if it is not the institution's charting method. Only document changes in the client's status.

Use abbreviations approved by the facility. Use abbreviations, but only those that are commonly accepted and approved by the facility. All documentation requires proper grammar and writing techniques. The nurse should be using the particular charting method for the employing institution. All care and observations should be documented - not only changes in a client's status.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Make inhalation longer than exhalation. Use diaphragmatic breathing. Use chest breathing. Exhale through an open mouth.

Use diaphragmatic breathing.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.

Use minimum disclosure policy to release the information. The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:

Use of accessory muscles indicates worsening breathing conditions. Assuming the tripod position, a 93% pulse oximetry reading, and a request for the nurse to raise the head of the bed don't indicate that the client's condition is worsening.

*Which component of the RAI?* Specified in state operation manuals that direct when and how to use the RAI.

Utilization guidelines

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function? Develops a plan of care Provides psychological support Completes preoperative assessment Verifies that operative consent is signed

Verifies that operative consent is signed

The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element?

Vitamin A Explanation: Dryness of the eyes (xerophthalmia) is associated with a deficiency of vitamin A.

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

Vitamin K

The nurse would identify which vitamin deficiency to prevent hemorrhaging during surgery? Vitamin K Magnesium Zinc Vitamin A

Vitamin K

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

Vitamin K Explanation: Specific foods may interact with medications, altering the effectiveness of the drug. Vegetables high in vitamin K decrease the effectiveness of the commonly used anticoagulant warfarin. Calcium, potassium, and Vitamin C do not interact with warfarin.

Which documentation by the nurse best supports the PIE charting system? Vomiting 250 mL undigested food, antiemetic given, no further vomiting States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea

Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).

What is occurrence/variance charting?

When a patient fails to meet an expected outcome in a planned intervention and the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, are charted when appropriate (The variances most likely to be documented are those that affect quality, cost, or length of stay.)

Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"? "You seem nervous about your surgery." "Relax. Your recovery period will be shorter if you're less nervous." "Stop worrying. It only makes you more nervous." "You needn't worry. Your doctor has done this surgery many times before."

You seem nervous about your surgery

The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?

a client who has a fever Explanation: A client who has a fever would have an increased BMR. The energy needs of the body are increased due to the client's fever. The BMR is decreased in an older adult client, a client who is fasting, and a client who is asleep.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client who is homebound and needs skilled nursing care a client whose rehabilitation potential is not good a client whose status is stabilized a client who is not making progress in expected outcomes of care

a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: a referral. a consultation. conferring. reporting.

a referral. Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? a) "Emotional lability is common after a stroke, and it usually improves with time." b) "You sound stressed; maybe using some stress management techniques will help." c) "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." d) "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?"

a) "Emotional lability is common after a stroke, and it usually improves with time." - This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? a) "I use this to prevent migraines." b) "I take this when I get a headache." c) "It constricts the blood vessels in my head." d) "It alleviates my sensitivity to light and sound."

a) "I use this to prevent migraines." - Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a) A 60-year-old Black man b) A 40-year-old White woman c) A 62-year-old White woman d) A 28-year-old pregnant Black woman

a) A 60-year-old Black man - The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.

Which term refers to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Agraphia c) Apraxia d) Perseveration

a) Agnosia - Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? a) Apply warm or cool cloths to the forehead or back of the neck. b) Maintain hydration by drinking eight glasses of fluid a day. c) Perform the Heimlich maneuver. d) Use pressure-relieving pads or a similar type of mattress.

a) Apply warm or cool cloths to the forehead or back of the neck. - Warmth promotes vasodilation; cool stimuli reduce blood flow.

Which interventions would be recommended for a client with dysphagia? Select all that apply. a) Assist the client with meals. b) Place food on the affected side of the mouth. c) Test the gag reflex before offering food or fluids. d) Allow ample time to eat.

a) Assist the client with meals. c) Test the gag reflex before offering food or fluids. d) Allow ample time to eat. - Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Bleeding b) Headache c) Increased intracranial pressure (ICP) d) Hypertension

a) Bleeding - Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cardiogenic emboli b) Cerebral aneurysm c) Arteriovenous malformation d) Intracerebral hemorrhage

a) Cardiogenic emboli - Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

Which insult or abnormality can cause an ischemic stroke? a) Cocaine use b) Arteriovenous malformation c) Trauma d) Intracerebral aneurysm rupture

a) Cocaine use - Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm rupture are associated with hemorrhagic stroke.

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? a) Decreased oxygen requirements b) Increased sputum production c) Normothermia d) Decreased activity tolerance

a) Decreased oxygen requirements A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke? a) Difficulty speaking b) Increase in heart rate c) Facial edema d) Electrolyte imbalance

a) Difficulty speaking - Difficulty speaking is a classic abnormal finding on a physical assessment that may be associated with a stroke. Tachycardia, edema, and electrolyte imbalances are not common initial presentations of stroke.

Which of the following is a symptom diagnostic of emphysema? a) Dyspnea b) Copious sputum production c) The occurrence of cor pulmonale d) Normal elastic recoil

a) Dyspnea Dyspnea is characteristic of emphysema. A chronic cough is considered the primary symptom of chronic bronchitis. Refer to Table 11-1 in the text

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute? a) Encourage the client to eat semisolid foods and cold foods. b) Encourage the client to drink hot liquids. c) Encourage the client to eat tepid foods. d) Encourage the client to eat solid foods.

a) Encourage the client to eat semisolid foods and cold foods. - When the client can resume oral intake after a CVA, individualize the diet according to his or her ability to chew and swallow. Semisolid and medium-consistency foods such as pudding, scrambled eggs, cooked cereals, and thickened liquids are easiest to swallow. Cold foods stimulate swallowing. The client should avoid tepid foods, because they are more difficult to locate in the mouth, and extremely hot foods, which can cause overreaction. Therefore options B, C, and D are incorrect.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client a) Has wheezes in the right lung lobes b) Cannot perform activities of daily living c) Has a respiratory rate of 28 breaths/minute d) Reports shortness of breath

a) Has wheezes in the right lung lobes Of the data listed, wheezing, an adventitious lung sound, is the best data that supports the diagnosis of ineffective airway clearance. An increased respiratory rate and a report of dyspnea are also defining characteristics of this nursing diagnosis. They could support other nursing diagnoses, as would inability to perform activities of daily living

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Heparin sodium b) Dexamethasone c) Methyldopa d) Phenytoin

a) Heparin sodium - Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? a) International normalized ratio greater than 2 b) Two hour time period of the stroke c) Taking digoxin d) Surgery 6 weeks ago

a) International normalized ratio greater than 2 - The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Intracranial hemorrhage b) Ischemic stroke c) Age 18 years or older d) Systolic blood pressure less than or equal to 185 mm Hg

a) Intracranial hemorrhage - Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? a) Ischemic b) Hemorrhagic c) Right-sided d) Left-sided

a) Ischemic - Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.

Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Lamotrigine (Lamictal) b) Phenytoin (Dilantin) c) Carbamazepine (Tegretol) d) Topiramate (Topamax)

a) Lamotrigine (Lamictal) - The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? a) Psychosis, disorientation, delirium, insomnia, and hallucinations b) Severe dementia and myoclonus c) Tremor, rigidity, and bradykinesia d) Choreiform movement and dementia

a) Psychosis, disorientation, delirium, insomnia, and hallucinations - Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? a) Respiratory acidosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory alkalosis

a) Respiratory acidosis As status asthmaticus worsens, the PaCO increases and the pH decreases, reflecting respiratory acidosis.

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? a) Three hours b) One hour c) Two hours d) Six hours

a) Three hours - Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? a) codeine b) hydrocodone c) morphine d) fentanyl

a) codeine - Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? a) impaired cerebral circulation b) cardiac disease c) diabetes insipidus d) hypertension

a) impaired cerebral circulation - TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.

The nurse is reviewing a client's understanding of dietary choices that will help reduce high triglyceride and cholesterol levels. Which statement by the client indicates an understanding fo the BEST options to be included in the diet? a. "I plan to use more sunflower oil in my diet selections." b. "Coconut oil has shown to be a good choice for people hoping to reduce cholesterol levels." c. "I am using palm oil in most of my cooking right now." d. "Palm kernel oil is a smart choice because it is one of the oils lowest in triglycerides and cholesterol."

a. "I plan to use more sunflower oil in my diet selections."

The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective? a. "When I take my medication, I will eat a banana or take it with a glass of orange juice." b. "I am going to increase my intake of dietary products like milk and cheese." c. "Because I am losing sodium with the medication, I need to increase my salt intake." d. "It would be better to eat small frequent meals each day instead of three large meals."

a. "When I take my medication, I will eat a banana or take it with a glass of orange juice."

A nurse is discussing vitamin supplementation. Which groups are more prone to milk vitamin deficiencies? a. adolescents b. middle-aged adults c. pregnant or lactating women d. non-smokers e. strict vegetarians

a. adolescents, c. pregnant or lactating women, e. strict vegetarians

A nurse is caring for a client with a G-tube and observes that a large amount of drainage is leaking from the tube. Upon inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take NEXT? a. apply gentle pressure to the tube while pressing the external bumper closer to the skin b. gently rotate the external bumper 90 degrees c. apply a skin barrier to the insertion site d. notify the health care provider

a. apply gentle pressure to the tube while pressing the external bumper closer to the skin

The nurse is teaching an older adult client about different types of proteins that can be eaten. Which foods will the nurse identify as containing dietary protein? a. beans b. nuts c. poultry d. butter e. fish

a. beans, b. nuts, c. poultry, e. fish

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching? a. blood from the fingertips shows changes in glucose more quickly than other testing sites b. use a forearm sample with signs and symptoms of hypoglycemia c. calibrate the glucose meter every 6 months d. glucose levels will decrease with illness and stress

a. blood from the fingertips shows changes in glucose more quickly than other testing sites

Which guideline is recommended when obtaining a capillary blood sample for glucose testing? a. calibrate the meter according to the manufacturer's recommendation and when a new bottle of test strips is opened b. use the scalp to obtain a blood sample from infants and children c. if the site to be accessed is warm, place a cool compress on the site before testing d. if blood glucose level results are above or below normal parameters, immediately notify the primary care provider for further instructions

a. calibrate the meter according to the manufacturer's recommendation and when a new bottle of test strips is opened

A nurse is caring for a client who reports frequent nausea. Which food should the nurse recommend to the client when the nausea is relieved? a. clear fruit juices b. boiled vegetables c. mashed potatoes d. carbonated beverages

a. clear fruit juices

A nurse is caring for a client with an NG tube. The nurse enters the room to flush the NG tube and check gastric residual. Which action should the nurse perform FIRST? a. ensure the HOB is elevated b. check placement of the tube c. flush the tube with the ordered amount of water d. aspirate gastric contents with a syringe

a. ensure the HOB is elevated

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: a. fluid and electrolyte levels b. ability to reposition c. pain level during infusion d. N/V

a. fluid and electrolyte levels

A nurse is delivering meal trays to clients on the unit. One client has a fractured dominant arm which is in a sling. What is the FIRST nursing action when bringing the tray into the client's room? a. identify the name of the client b. remove the lids covering the foods c. assist the client with opening containers of liquids d. cut food into bite-size pieces

a. identify the name of the client

A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which lab finding may suggest the need for nutritional support? a. low prealbumin levels b. proteinuria c. low random blood glucose levels d. increased WBC

a. low prealbumin levels

When a client provides a return demonstration of appropriate food selections for carbohydrates, which food does the nurse acknowledge as rich in carbohydrates? a. milk b. oatmeal c. bread d. chicken e. beef

a. milk, b. oatmeal, c. bread

During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-moth-old infant. What does the nurse inform the parent? a. new foods should be introduced one at a time for a period of 2-3 days b. it is too early to add solid foods to the infant's diet c. a new solid food should be introduced daily to the infant's diet for a week d. adding solid foods is fine at this age, but avoid iron-fortified foods

a. new foods should be introduced one at a time for a period of 2-3 days

The nurse is caring for a client with a G-tube and notes a patchy, red rash at the insertion site. Which action would be MOST appropriate to address this concern? a. notify the HCP for a prescription to apply an anti fungal powder b. apply gentle pressure to the tube while pressing the external bumper closer to the skin c. administer an antibiotic as prescribed d. apply a skin barrier to the insertion site

a. notify the HCP for a prescription to apply an anti fungal powder

The nurse is preparing to obtain an adult client's capillary blood sample for glucose testing. Which action is appropriate? a. obtain the blood sample from the edges of the fingers rather than the center of the fingertip b. squeeze and "milk" the finger if the initial blood droplet size is too small c. smear a drop of blood into the test strip d. apply an alcohol pad to the puncture site after the sample is obtained

a. obtain the blood sample from the edges of the fingers rather than the center of the fingertip

A nurse has just inserted an NG tube in a client. Which method is MOST reliable for verifying the correct placement of the tube? a. radiographic confirmation of position b. confirmation that pH of the pirate is less than 5.5 c. green fluid with particles aspirated d. off-white fluid aspirated

a. radiographic confirmation of position

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate? a. speak to the client but limit the need for the client to respond verbally while chewing and swallowing b. arrange food items in a clock face pattern and inform the client which time on a clock corresponds to each food item c. create a positive social environment by asking the client about childhood food memories d. encourage the client to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm

a. speak to the client but limit the need for the client to respond verbally while chewing and swallowing

Which nutrient does the nurse identify as appropriate for a client with a normal dietary order who is consuming 2,000 calories daily? a. total fat less than 65g b. cholesterol greater than 300mg c. sodium less than 2,000mg d. saturated fat greater than 20mg

a. total fat less than 65g

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change? a. try eating foods that are attractive and at the proper temperature b. try eating 2-3 foods at a time c. try eating foods with the same textures and aromas d. use spicy condiments to add flavor

a. try eating foods that are attractive and at the proper temperature

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?

adolescent who is in the second trimester of pregnancy Explanation: Children, adolescents, pregnant women, and breast-feeding mothers require more servings per day of certain food groups, particularly the milk group. Therefore, the adolescent who is pregnant will require more milk servings. The other clients do not require more servings of milk.

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client? hypoglycemia obstruction surgical site infection adrenal insufficiency

adrenal insufficiency

The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's PRIORITY action?

assess the client for signs and symptoms of hypoglycemia

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." b) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." c) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." d) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."

b) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? a) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." b) "The client is unaware of his left side. You should approach him on the right side." c) "The client is unaware of his left side. You need to encourage him to interact from this side." d) "This condition is temporary."

b) "The client is unaware of his left side. You should approach him on the right side." - The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his unaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

Although many signs and symptoms lead to a diagnosis of emphysema, one symptom stands as the primary presenting symptom. Which of the following is the primary presenting symptom? a) Tachypnea b) Dyspnea c) Wheezing d) Chronic and persistent cough

b) Dyspnea Dyspnea may be severe and often interferes with the patient's activities. It is usually progressive, worse with exercise, and persistent. As COPD progresses, dyspnea may occur at rest. Chronic cough and sputum production often precede the development of airflow limitation by many years. However, not all people with cough and sputum production develop COPD. The cough may be intermittent and unproductive in some patients.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? a) Speaking loudly b) Establishing eye contact c) Avoiding the use of hand gestures d) Speaking in complete sentences

b) Establishing eye contact - The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a) Nausea, vomiting, and profuse sweating b) Hemiplegia, seizures, and decreased level of consciousness c) Difficulty breathing or swallowing d) Tachycardia, tachypnea, and hypotension

b) Hemiplegia, seizures, and decreased level of consciousness - Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a) It decreases use of accessory breathing muscles. b) It helps prevent early airway collapse. c) It prolongs the inspiratory phase of respiration. d) It increases inspiratory muscle strength.

b) It helps prevent early airway collapse. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Transient ischemic attack (TIA) b) Left-sided cerebrovascular accident (CVA) c) Right-sided cerebrovascular accident (CVA) d) Completed Stroke

b) Left-sided cerebrovascular accident (CVA) - When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

The nurse is educating a patient with asthma about preventative measures to avoid having an asthma attack. What does the nurse inform the patient is a priority intervention to prevent an asthma attack? a) Staying in the house if it is too cold or too hot b) Preparing a written action plan c) Using a long-acting steroid inhaler when an attack is coming d) Avoiding exercise and any strenuous activity

b) Preparing a written action plan Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations (Expert Panel Report 3, 2007).

A client tells the nurse, "As long as I only eat 2,400 calories per day, it does not matter which foods I eat." Which response by the nurse is BEST? a. "Be sure to eat a large amount of carbohydrates so you can have energy." b. "Can you share an example of what you ate yesterday?" c. "As long as you can focus on protein intake, you will get the nutrition you need." d. "It does not matter which foods you eat, as long as you always make sure you get 2,400 calories."

b. "Can you share an example of what you ate yesterday?"

The nurse is assessing clients for BMR. Which client would the nurse suspect would have an increased BMR? a. an older adult client b. a client who has a fever c. a client who is fasting d. a client who is asleep

b. a client who has a fever

A nurse is caring for a client who had an appendectomy earlier in the day. The client now has bowel sounds and is passing flatus. Which food is appropriate for the nurse to serve to the client at this time? a. sherbert b. apple juice c. Ensure d. chopped fruit

b. apple juice

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed FIRST? a. flush the NG tube with the ordered amount of water b. aspirate stomach contents and check pH c. check gastric residual d. pour a remeasured amount of tube feeding formula into the NG tube

b. aspirate stomach contents and check pH

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the BEST action for the nurse to take? a. chop the client's food to make it easier to swallow b. check the medical record for the client's prescribed diet c. offer the client a sip of water in between each bite d. replace the client's meal tray with soft foods available on the unit

b. check the medical record for the client's prescribed diet

Which nursing action associated with successful tube feedings follows recommended guidelines? a. check the tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid b. check the residual before each feeding or every 4-6 hours during a continuous feeding c. assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract d. prevent contamination during enteral feedings by using an open system

b. check the residual before each feeding or every 4-6 hours during a continuous feeding

A nurse is providing care for a diverse group of clients on a medical floor. Which tasks may the nurse delegate to the UAP? a. obtaining a nasal swab from a client with flu-like symptoms b. checking a client's capillary blood glucose level c. obtaining an arterial blood gas specimen from a client with lung disease d. obtaining a client's stool specimen for occult blood testing e. collecting a midstream urine specimen from a client with flank pain

b. checking a client's capillary blood glucose level, d. obtaining a client's stool specimen for occult blood testing, e. collecting a midstream urine specimen from a client with flank pain

A nurse is caring for a client who is receiving TPN. Which action should the nurse perform with TPN? a. check vital signs every 8 hours b. discard unused TPN every 24 hours c. monitor blood glucose levels every 12 hours d. change transparent dressings every day

b. discard unused TPN every 24 hours

A nurse is preparing to obtain a client's capillary blood sample for glucose testing. The nurse should perform which action? a. prepare the lancet using clean technique b. hold the lancet perpendicular to the skin and prick the site c. encourage bleeding by raising the hand above heart level d. gently smear a drop of blood on the pad of the test strip

b. hold the lancet perpendicular to the skin and prick the site

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? a. use a small syringe and insert 10mL of water b. if fluid is obtained when aspirating, measure its volume and pH and flush the tube with water c. continue to instill air until fluid is aspirated d. place the client in the trendelenburg position to facilitate the fluid aspiration process

b. if fluid is obtained when aspirating, measure its volume and pH and flush the tube with water

A nurse is administering a prescribed dose of IV fluid to a young client with anorexia at the health care facility. Which information regarding contributing factors should the nurse include when educating the family? a. poor nutrition can contribute to anorexia b. illness can contribute to anorexia c. ADHD can contribute to anorexia d. the client's age can contribute to anorexia

b. illness can contribute to anorexia

A client is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding? a. feeds must be warmed prior to instillation to reduce the risk of N/V b. intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time c. continuous feedings are the preferred method of introducing the formula over a set period of time via gravity or pump d. feeding intolerance is less likely to occur with larger volumes

b. intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time

A client with protein deficiency is encouraged to eat a protein-rich snack. The client requests a peanut butter sandwich. What other food can the nurse provide that will provide the client with complete protein? a. wheat bread b. milk c. celery d. carrots

b. milk

The nurse is caring for a client who is pregnant. Which nutrition education will the nurse provide? a. weight gain is not an issue since the client is pregnant b. more servings of milk daily will be required c. eliminate red meat and poultry from the diet d. decrease intake of carbohydrates, such as grains

b. more servings of milk daily will be required

Which vitamin is found only in animal foods? a. vitamin C b. vitamin B12 c. vitamin A d. vitamin D

b. vitamin B12

The nurse is teaching an older adult client about different types of proteins that can be eaten. Which foods will the nurse identify as containing dietary protein? Select all that apply.

beans nuts poultry fish Explanation: Dietary proteins are obtained from animal and plant food sources, which include milk, meat, fish, poultry, eggs, soy, legumes (peas, beans, and peanuts), nuts, and components of grains. Butter is a fat and not a source of protein.

A client has been found to be deficient in vitamin K. For what complication will the nurse closely assess, because it is related to this deficiency?

bleeding tendencies Explanation: A deficiency in vitamin K will cause bleeding tendencies related to the inability for the blood to clot appropriately. Visual disturbances may indicate a deficiency in vitamin A. Alterations in calcium levels may indicate a deficiency in vitamin D. Cardiac arrhythmias may be caused by potassium, calcium, magnesium deficiency.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for? a) Emphysema b) Pleurisy c) Atelectasis d) Pneumonia

c) Atelectasis In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following? a) Moderate amounts of low-fat dairy products b) Moderate amounts of animal protein c) High amounts of low-fat dairy products d) Moderate amounts of fruits and vegetables

c) High amounts of low-fat dairy products - The DASH diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) Decreased level of consciousness (LOC) b) Elevated blood pressure c) Increased urine output d) Decreased heart rate

c) Increased urine output - The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? a) 12-lead electrocardiogram b) Carotid ultrasound study c) Noncontrast computed tomogram d) Transcranial Doppler flow study

c) Noncontrast computed tomogram - The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment? a) Monitoring the pulse oximetry to assess need for early intervention when PCO2 levels rise b) Increasing pH c) Providing sufficient oxygen to improve oxygenation d) Avoiding the use of oxygen to decrease the hypoxic drive

c) Providing sufficient oxygen to improve oxygenation The main objective in treating patients with hypoxemia and hypercapnia is to give sufficient oxygen to improve oxygenation.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? a) Dilated and reactive pupils b) Heart rate of 100 beats/minute c) Respiratory rate of 22 breaths/minute d) Urine output of 40 ml/hour

c) Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? a) large-artery thrombotic b) small, penetrating artery thrombotic c) cardio embolic d) cryptogenic

c) cardio embolic - Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

A nurse is checking a client's capillary blood glucose level. Which nursing action is MOST appropriate? a. cleanse the test strip with an alcohol swab prior to inserting it in the meter b. have the client make a fist to encourage blood flow c. touch the test strip directly to a drop of blood d. wipe the test site with an alcohol swab after testing

c. touch the test strip directly to a drop of blood

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? -large-artery thrombotic -small, penetrating artery thrombotic -cardio embolic -cryptogenic

cardio embolic Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? SOAP narrative focus charting by exception

charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? charting by exception (CBE) FOCUS charting problem, intervention, evaluation (PIE) charting variance charting

charting by exception (CBE) Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. FOCUS charting does not use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column. The focus may be a client strength, problem, or need. Problem, intervention, evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome, or when a planned intervention is not implemented in the case management model.

What ensures continuity of care? reassessment critical thinking communication integration

communication Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to continuity of care.

To _______ is to consult with someone to exchange ideas or to seek information, advice, or instructions.

confer

A ________________ is the process of inviting another professional to evaluate the patient and make recommendations to you about the patient's treatment

consultation

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: continuously monitors the sedated client. assesses how well the client is recovering from anesthesia. performs a complete assessment of the client. obtains a surgical consent from the client's mother.

continuously monitors the sedated client.

The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply.

cured ham table salt bacon Explanation: Sodium is found in higher concentrations in table salt, bacon, and processed meats. The other choices do not have a high concentration of sodium.

A physically fit older adult is scheduled for right knee replacement. What factor for the client creates an increased risk for postoperative complications? type of surgery ability to metabolize medication surgical site current smoking history

current smoking history

Which method of feeding would a nurse normally provide if a client can attempt eating regular meals during the day and is prepared to ambulate and resume activities?

cyclic feeding

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use? a) "I lubricate my lips and nose with K-Y jelly." b) "I clean my mask with water after every meal." c) "I have a 'no smoking' sign posted at my front door to remind guests not to smoke." d) "I make sure my oxygen mask is on tightly so it won't fall off while I nap."

d) "I make sure my oxygen mask is on tightly so it won't fall off while I nap." The client requires additional teaching if he states that he fits his mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly. Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a water-soluble lubricant, such as K-Y jelly, to prevent drying. Smoking is contraindicated wherever oxygen is in use; posting of a "no smoking" sign warns people against smoking in the client's house. Cleaning the mask with water two or three times per day removes secretions and decreases the risk of infection.

Emphysema is described by which of the following statements? a) A disease that results in a common clinical outcome of reversible airflow obstruction b) Chronic dilatation of a bronchus or bronchi c) Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of 2 consecutive years d) A disease of the airways characterized by destruction of the walls of overdistended alveoli

d) A disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of over-distended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli. Also, a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of 2 consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agnosia b) Agraphia c) Perseveration d) Apraxia

d) Apraxia - Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.

A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat? a) Fish, meats, and vegetable oils b) Citrus fruits c) Milk and dairy products d) Cereals, soybeans, and spinach

d) Cereals, soybeans, and spinach - Clients who take warfarin (Coumadin) must be informed that they should eat foods rich in vitamin K. Examples of food sources of vitamin K include cabbage, cauliflower, spinach, and other green leafy vegetables, cereals, and soybeans. Other food groups are not known to contain vitamin K. Milk and dairy products are good sources of calcium, while citrus fruits are sources of vitamin C. Fish, meats, and oils are sources of proteins and fats.

The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? a) Neck pain rated 3 of 10 (on a 0 to 10 pain scale) b) Blood pressure 128/86 mm Hg c) Mild neck edema d) Difficulty swallowing

d) Difficulty swallowing - The client's inability to swallow without difficulty would cause the nurse the most concern. Difficulty swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The client's neck pain and mildly elevated blood pressure need to be addressed but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse? a) Sexual history b) Motor and sensory responses c) Blood pressure and weight d) Frequent neurologic checks

d) Frequent neurologic checks - If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. Body weight is measured because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease, and not in the case of carotid artery surgery. Sexual history and motor and sensory responses are not important assessments to be performed for such clients.

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Left-sided stroke b) Right-sided stroke c) Cerebral aneurysm d) Transient ischemic attack

d) Transient ischemic attack - A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: a) allow time for the client to respond. b) speak loudly and articulate clearly. c) give the client a writing pad. d) use short, simple sentences.

d) use short, simple sentences. - Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor? a. "Colorectal cancer is not as common in vegetarians compared to people who eat high fat diets." b. "Protein complementation is important to help the client get the needed amino acids." c. "Semi-vegetarians exclude red meat from their diet and seek protein elsewhere." d. "According to research, vegetarians have a higher incidence of obesity than others."

d. "According to research, vegetarians have a higher incidence of obesity than others."

The nurse is providing education about nutrition and feeding to the parent of a toddler. Which statement by the child's parent indicates understanding of the education? a. "It is important for my child to avoid finger feeding and use utensils." b. "Providing small finger snacks such as grapes or hot dogs is a good idea." c. "Fruit slices with the skins will be a healthy choice for my child d. "Boiled eggs and pieces of cheese are good snacks for my child."

d. "Boiled eggs and pieces of cheese are good snacks for my child."

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching? a. "My body does not make its own vitamins." b. "Cooking can change the vitamin contents in foods." c. "I drink orange juice fortified with added calcium." d. "My husband and I are ordering product that has megadoses of vitamins."

d. "My husband and I are ordering product that has megadoses of vitamins."

A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene? a. "Vegetarians have a lower incidence of colorectal cancer than people who eat high fat diets." b. "Protein complementation is important so that you get the right amount and proportion of amino acids needed." c. "Vegans consume plant sources for protein." d. "Obesity is closely linked with vegetarianism."

d. "Obesity is closely linked with vegetarianism."

The nurse is caring for four older clients. Which does the nurse identify as HIGHEST risk for cardio metabolic syndrome? a. 50yo who is of normal weight b. 53yo with bust larger than hips c. 56yo with hips larger than bust] d. 59yo with bust, abdomen, and hips of similar proportion

d. 59yo with bust, abdomen, and hips of similar proportion

A nurse is caring for a client with a g-tube in place. Which is an accurate guideline for care of the insertion site? a. if the G-tube is new, dip a cotton-tipped applicator into hydrogen peroxide and apply pressure to clean the site b. if the g-tube is new and has crusts or drainage, do not disturb the site by cleaning it c. adjust of lift the external disk for the first few days after placement to keep crusts from forming d. if the G-tube insertion site has healed and the sutures are removed, use soap and water to clean the site

d. if the G-tube insertion site has healed and the sutures are removed, use soap and water to clean the site

The nurse is reviewing a client's lab report. The report indicates the client's albumin level is 2.89g/L (4/19mmol/L). Which inference can the nurse make about the lab result? a. the client has an infection b. the client has been taking steroids c. the client has likely been on a high protein diet d. the client has malnutrition

d. the client has malnutrition

A family meeting has been called to discuss care planning for a client who has late-stage Alzheimer disease and who has largely stopped taking food by mouth. What principle should BEST guide the decision around the use of tube feeding? a. tube feeding has the potential to meet the client's short and long term hydration and nutrition needs b. the client will require parenteral supplements in addition to tube feeding c. tube feeding is not an option if the client is unable;e to manipulate the system independently d. tube feeding has not been shown to increase survival rates significantly among this population

d. tube feeding has not been shown to increase survival rates significantly among this population

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia? corticosteroids diuretics insulin anticoagulants

diuretics

What does the nurse recognize as purposes of the electronic health record? Select all that apply. documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research defending health care personnel during practice lawsuits

documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research The electronic health record provides an avenue to document continuity of care, qualify health care providers for government funds, ensure client safety, and facilitate health education and research. It can provide evidence during practice lawsuits, however, that is not the purpose of the electronic health record.

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply. education of student nurses reimbursement for services research giving information over the phone when unidentified callers call the hospital unit education for medical students

education of student nurses reimbursement for services research education for medical students The client medical record may be used for education of a variety of health care professionals, reimbursement, and research. The record is never used to give information to callers without written authorization from the client.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as emergency. urgent. required. elective.

emergency

A woman consumes pasta, grains, and other carbohydrates for which purpose?

energy Explanation: The main function of carbohydrates is to provide energy.

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

every 4-6 hours

Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is:

extremely obese

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:

fluid and electrolyte levels. Explanation: Total parenteral nutrition (TPN) is nutrition administered through a central venous access and is high in nutrients and electrolytes. It is important to assess fluid and electrolyte levels with TPN infusions. Falls are a risk associated with ability to reposition and not TPN. There is no pain associated with TPN infusions as the medication is administered via a central venous access line. Nausea or vomiting are not adverse effects associated with TPN as the medication is administered via a central line and not by a feeding tube in the stomach.

The nurse is preparing to educate a pregnant client who is in the clinic for the first prenatal appointment. Which vitamins or minerals will the nurse include in the teaching to prevent neural tube defects in the fetus?

folic acid

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results? progress note admission nursing assessment graphic sheet medical record

graphic sheet The graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.The admission nursing assessment records the findings of the nursing history and physical assessment upon admission.

The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550mL. The previous residual was 200mL. What action should the nurse take?

hold the enteral nutrition and notify the primary care provider

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation? immediately report the suspected abuse of the client. avoid reporting the abuse as it would be a privacy and confidentiality violation inform the client's family that the client is being neglected at home discuss the abuse with coworkers to determine what should be done

immediately report the suspected abuse of the client. The nurse is a mandatory reporter and state laws take precedence over Health Insurance Portability and Accountability Act (HIPAA)/ Personal Information Protection and Electronic Document Act (PIPEDA) regulations. The priority action by the nurse is to report the suspected abuse to the adult protective service department so that it can be investigated. It is not appropriate to involve the family members at this point because it may mask any abuse that is occurring. The fewer people involved in this situation is better. The nurse should not discuss this with coworkers unless they are directly involved with the client's care.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? -impaired cerebral circulation -cardiac disease -diabetes insipidus -hypertension

impaired cerebral circulation TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.

interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

iodine

A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?

low prealbumin levels Explanation: Prealbumin levels are a good indicator of a client's short-term nutritional status; decreased levels are suggestive of malnutrition. Protein in the client's urine, low blood sugars, and increased white blood cells are not necessarily indicative of malnutrition. Proteinuria is urine having an abnormal amount of protein. The condition is often a sign of kidney disease. Random blood sugar can be affected by food intake. White blood cells are indicative of infection.

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet?

maintenance of normal bowel elimination Explanation: Dietary fiber is a minimal source of energy but plays an essential role in stimulating peristalsis and maintaining normal bowel elimination. Proteins have specific functions of producing hemoglobin for carrying oxygen to tissues, insulin for blood glucose regulations, and albumin for regulating osmotic pressure in the blood. Fats perform the important functions of energy storage of adipose tissue, vitamin absorption, and transport of fat-soluble vitamins A, D, E, and K.

What should the nurse consider when teaching a man with well-defined muscle mass about meal planning?

men have a higher need for protein

A client with protein deficiency is encouraged to eat a protein-rich snack. The client requests a peanut butter sandwich. What other food can the nurse provide that will provide the client with complete protein?

milk Explanation: Complete proteins, such as milk, typically come from animal sources. Proteins from plant sources, such as soybeans, are usually incomplete. Carrots and bread are not significant protein sources.

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. Explanation: Niacin, part of the B vitamins, has a known side effect of flushing and itching after ingestion. The other vitamins that make up the B complex vitamin are B1 thiamin, B2 riboflavin, B3 niacin, B5 pantothenic acid, B6 pyridoxine, B7 biotin, B9 folic acid, and B12 cobalamin. Other adverse effects of the B complex vitamins include nausea, vomiting, constipation, abdominal pain, and black stools.

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. physical condition age health status gender Ethnicity nutritional status

nutritional status age physical condition health status

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?

overweight Explanation: A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply. postoperative pain control cough and deep-breathing exercises the client's spouse's thoughts about the upcoming surgery intravenous fluids and other lines and tubes the surgeon's fee and other hospital charges

postoperative pain control cough and deep-breathing exercises intravenous fluids and other lines and tubes

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse? sodium 138 mEq/L potassium 6.2 mEq/L white blood cell count 7.2 cells/mm calcium 9.8 mg/dL

potassium 6.2 mEq/L

Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply.

pregnant adolescents people with substance use problems older adults living on fixed incomes Explanation: Examples of those in the United States at risk for an inadequate nutritional intake include older adults who are socially isolated or living on fixed income, homeless people, children of economically deprived parents, pregnant adolescents, people with substance use problems, and clients with eating disorders. Children of middle-income parents and individuals who prefer to purchase food from local farmers are not necessarily at risk.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? data base problem list plan of care progress notes

progress notes In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

Patient _________ contain data used to facilitate quality, evidence-based care, serve as financial and legal records, help in clinical research and support decision analysis.

records

A __________________ is the process of sending or guiding the patient to another source for assistance

referral

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: reimbursement. staff development. research. change of mechanisms.

reimbursement. Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits do not play a role in staff development, research, or change of mechanisms within a system.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? subjectivity objectivity organization reimbursement

subjectivity Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

During a general survey, the nurse documents the was it circumference of an overweight female client as 43in (109cm). What teaching should the nurse include about the risks associated with this was it circumference?

the client is at risk for diabetes

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? those directly involved in the client's care any family member of the client close friends of the client health care professionals of the facility

those directly involved in the client's care Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy applicable to each client. Health care professionals of the health care facility may not access client information unless involved in that client's care at that time..

A nurse teaches a student nurse about the role fats play in the human body. What is the major storage form of fat?

triglycerides Explanation: Triglycerides are the predominant form of fat in food and the major storage form of fat in the body, composed of one glyceride molecule and three fatty acids. Trans fat is a product that results when liquid oils are partially hydrogenated. These oils then become more stable and solid. Trans fats raise serum cholesterol levels. Cholesterol is a fat-like substance, found only in animal tissues, which is important for cell membrane structure, a precursor of steroid hormones and a constituent of bile. Lipid is a group name for fatty substances, including fats, oils, waxes, and related compounds.

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?

try to ensure that the Clint's food is attractive and sufficiently warm

A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into? required emergent elective urgent

urgent

When communicating with a client who has sensory (receptive) aphasia, the nurse should: -allow time for the client to respond. -speak loudly and articulate clearly. -give the client a writing pad. -use short, simple sentences.

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

A client's record can be more accurate if the nurse: charts at least every 6 hours. uses point-of-care documentation. summarizes client care at the end of the shift. delegates charting appropriately.

uses point-of-care documentation. Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours.

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate?

vegetable plate for a client who practice Hinduism Explanation: Dietary restrictions associated with religions are extremely important to provide culturally competent nursing care. Clients who practice Hinduism do not consume beef, because cows are considered a sacred creature. They are typically vegetarians; therefore, a vegetable plate is appropriate for this client. Clients who practice Orthodox Judaism eat have kosher foods. Shrimp and pork are prohibited in a kosher diet. Members of The Church of Jesus Christ of Latter-day Saints do not drink coffee, tea, or alcohol and they limit their meat consumption.

Which vitamin is found only in animal foods?

vitamin B12 Explanation: Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?

vitamin D Explanation: Severe vitamin D deficiency manifests as rickets, osteomalacia, poor dentition, and tetany.

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which client surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? liver dysfunction nutrient deficiencies respiratory complications wound healing

wound healing

You should only document assessments and interventions that __________ perform.

you

Choice Multiple question - Select all answer choices that apply. A nurse is caring for a male patient with COPD. While reviewing breathing exercises, the nurse instructs the patient to breathe in slowly through the nose, taking in a normal breath. Then, the nurse asks the patient to pucker his lips as if preparing to whistle. Finally, the patient is told to exhale slowly and gently through the puckered lips. The nurse teaches the patient this breathing exercise to accomplish which of the following? Select all that apply. a) Release trapped air in the lungs b) Condition the inspiratory muscles c) Strengthen the diaphragm d) Prevent collapse of the airways e) Control the rate and depth of respirations

• Release trapped air in the lungs • Control the rate and depth of respirations • Prevent collapse of the airways The nurse is teaching the patient the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases trapped air in the lungs, and helps the patient control the rate and depth of respirations. This helps patients relax and get control of dyspnea and reduces the feelings of panic they experience. Diaphragmatic breathing strengthens the diaphragm during breathing. In inspiratory muscle training the patient will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.