ATI Review
Nurse in oncology clinic is assessing client who is undergoing treatment for ovarian cancer. Which statement by client indicates she is experiencing psyhological distress?
"My parents are retired, and they have come to help out with our children." - social and emotional support system "I am going to ask my husband to go to counseling with me." - open communication and counseling "I keep having nightmares about my upcoming surgery."- nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress that place client at risk for psychological distress "My girlfriends bought me a nice wig."- social and emotional support system
Nurse on rehab unit is preparing to transfer client who is unable to walk from bed to wheelchair. Which technique should nurse use?
- stand in front of client toward affected side - place wheelchair at 45 degree angle - instruct the client to lean forward from the hips. -assume a wide stance with one foot in front of the other
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insultin to mix together and administer subcutaneously (SQ). Determine the correct order of steps for the procedure.
1. Inject 10 units of air into the bottle of NPH insulin without touching needle to solution 2. Inject 5 units of air into bottle of regular insulin 3. Withdraw correct dose of regular insulin from the bottle 4. Insert needle into NPH insulin vial and withdraw correct dose of NPH insulin from the bottle N R to R N
A nurse performing abdomen assessment on older adult client. Identify correct sequence of steps for this assessment.
1. Inspect 2. Auscultate 3. Percuss 4 Palpate to prevents altering the bowel sounds and causing false results, but everywhere else in the body is assessed by IPPA (inspect, palpate, percuss, ausculate)
Nurse is called away for emergency while conversing with client who is concerned with diagnosis. The nurse returns promptly as promised.
Autonomy- clients right to make decisions. Fidelity - keeping promise Nonmaleficence - to do no harm. Justice - to treat everyone fairly.
trendelenburg position lay on unaffected side of lung to promote drainage perform percussions over single layer of clothing use cupped hand to do percussions
Chest Physiotherapy
C.difficile
Contact Isolation precautions -wear gloves when handling contaminated articles such as gown, sheets etc -use soap and water to cleanse as alcohol sanitizer is ineffective against spores - instruct client to remain in room, but move cough and deep breathe x 2 hours
A nurse caring for client with acute renal failure. Which assessment proides accurate measurement of fluid status?
Daily weight (provides important info on fluid status; a gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid) Blood pressure (nost most accurate indicator of fluid changes) Specific gravity (reflects kidney's ability to concentrate urine and is not most accurate method to measure fluid changes) Intake and output (reflects client's fluid status but is not the most accurate method)
Client with SOB requests nurses help in changing positions. After repositioning, which action should nurse take next?
Encourage the client to take deep breaths (this can increase intake of oxygen, but not priority) Observe the rate, depth, and character of the client's respirations. (plan care by starting with assessment or data collection of respiratory status to provide knowledge to make appropriate decision for interventions) Prepare to administer oxygen (oxygen is frequently administered when a client is experiencing dyspnea, but not priority) Give the client a back rub to help her relax (can reduce dyspnea., but not priority action)
- hold upper lid against eyebrow and lower lid against cheek bone (exert pressure on bony prominences to hold eyelids open) - hold solution 2.5 cm or 1 inch above the eye - direct irrigation solution from inner canthus to outer canthus and onto lower conjunctival sac
Eye Irrigation
Nurse is preparing to perform mouth care to unresponsive PT. Which action shuold the nurse plan to take?
Place the client supine. To prevent the risk of aspiration, the nurse should raise the client's head to 30° or turn the client to a side-lying position. Keep both side rails up. To prevent straining and the risk of self-injury, the nurse should lower the near side rail before performing mouth care. Raise the level of the bed. MY ANSWER The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury. Inspect the client's mouth using a finger sweep. To prevent the risk of care-giver injury, the nurse should never insert fingers into the mouth of an unresponsive client.
A nurse on med-surg is washing hands prior to assisting with surgical procedure. Which action by nurse demonstrates proper surgical hand-washing technique?
The nurse washes each part of her hands with 5 strokes. Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes. The nurse washes from the elbows down to the hands. MY ANSWER An important principle of surgical handwashing is to scrub the hands first, then work toward the elbows. The nurse washes with her hands held higher than her elbows. The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area. The nurse uses minimal friction when washing her hands. Scrubbing is performed with a specially designed and premedicated brush when performing surgical hand-washing. The use of mechanical friction is necessary to decontaminate the skin effectively.
Nurse is caring for client with prescription for vest restraint.
apply the restraint over the client's clothing allow 2 fingers btw restraint and client's chest do not fasten ties on the restraint to the side rails. Tie the restraint with a quick-release knot. that can be untied easily in case client's must be removed quickly
Peripheral Pulses
dorsalis pedis - top of the foot in groove between tensons of big toe and best felt by moving fingertip between 1-2 toe slowly up the foot popliteal pulse - behind knee best felt when flexed and foot resting on exam table posterior tibial pulse - inner side of ankle and best felt when foot is relaxed and extended femoral pulse - inguinal area best felt when lying down and area is exposed
glaucoma obstruction of flow of vitreous humor in the eye which leads to increase in intraocular pressure resulting in eye damage retinopathy - changes in blood vessels of retina can lead to blindness cataracts - increase opacity of lens blocking rays of light from entering the eye and causing halo to form macular degeneration - changes in sharp and central vision associated with aging
eye disorders
uncontrolled production of blast cells or immature WBC in bone marrow
leukemia
increase in circulating WBC in response to WBC exiting blood vessels in response to inflammation
leukocytosis
A nurse is caring for a client with Herpes Zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?
- acupuncture creates an open portal on the skins surface and is not recommended for skin infections or Herpes Zoster as it may increase the risk of further infection - biofeedback is used for clients with disease processes (stroke recovery, smoking cessation, headache) - aloe is used by clients with skin disorders as it promotes wound healing - feverfew is used for wound healing and should not be used by clients prescribed to Warfarin or anticoagulants
Applying cold therapy for sprained ankle.
- check cap refill and pulses before applying ice pack to affected area - do not apply cold pack to area with edema as it decreases circulation further and prevents absorption - fill ice pack 2/3 of way full with crushed ice - apply ice pack for 30 min intervals to anesthese and prevent swelling
abdominal trauma findings to indicate hypovolemic shock
- cool, clammy skin - urine output of 30 mL or less - tachycardia - tachypnea
Women Prevention and Health Promotion
- eye exam x 2 yrs - pap test x 3 yrs ages 30-65 - mammogram annually for 45 and up - mammorgram x 2 yrs 55 and up - colonoscopy x 10 yrs
Reduce Fall Risk
- monitor client frequently - keep bed in low position - create elimination schedules - use gait belt when ambulating - place in room near nurses station
Assisting with Mealtimes for dysphagia
- sit upright, lean slightly forward and til head foward and tuck chin downward to help swallow - provide thick fluids to prevent aspiration
Wound Culture Specimen
- wear clean gloves to collect specimen - cleanse wound with .9% sodium chloride or sterile water to remove surface debris or old exudate - rotate the swab back and forth over clean areas in base of wound to collect pathogens causing wound infection as edges of the wound or pooled drainage may contain other organisms
A nurse providing pre-op teaching for patient scheduled for arthroplasty next month may require blood transfusion. Client expresses concern about risk of acquiring infection from transufion. Which statement should nurse make to client?
"Ask your provider to prescribe epoetin before the surgery." Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery can boost the client's hematocrit levels, it is inappropriate if the client already has an adequate hematocrit level. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks. "You should ask your provider about taking iron supplements prior to the surgery." While taking an iron supplement prior to surgery can boost the client's hemoglobin levels, it is inappropriate if the client already has an adequate hemoglobin level and intake of iron from dietary sources. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks. "Request a family member to donate blood for you." A blood donation from a family member does not eliminate the risk of acquiring an infection. "Donate autologous blood before the surgery." MY ANSWER Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.
Adolescent client in outpatient mental health facility tells nurse that its hard to follow treatment plans because his friends discourage him. Which statement should nurse make?
"Don't worry, teenagers often have friends who give them bad advice." (sterotypical response does not encourage open communication) "I think you should stop seeing those friends since they discourage you from following your treatment plan." (nurse is giving personal advice and this response will be rejected by adolescent and will not encourage open communication) "Tell me more about how your friends discourage you." (asks open-ended question to encourages the client to elaborate about the problems that he is having) "Tell me where you met these friends." (change of subject and this response will not encourage open communication.)
Nurse is planning to insert NG tube. After explaning procedure, client states "you are not putting that hose down my throat" which statement should nurse make in response?
"I would try to get it over with because you won't get better without this tube." This is a nontherapeutic response because the nurse is blocking communication by giving advice and by threatening the client. "You should talk to your provider about it." This response by the nurse is blocking communication by rejecting the client's concerns and putting the client's feelings on hold, referring them to another person at a later time. "Why don't you want the tube inserted?" MY ANSWER The nurse should avoid "why" questions. This response is also passing judgment, which is a barrier to communication. "I can see that this is upsetting you." The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.
Nurse is explaining use of written consent forms. The nurse should ensure that written consent form has been signed by which client?
A client who has a prescription for a transfusion of packed red blood cells Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure. A client who is being transported for a radiography of the kidneys, ureters, and bladder MY ANSWER Clients admitted to a hospital sign a general consent form when admitted. This form allows consent for this diagnostic examination. A client who has a prescription for a tuberculin skin test Implied consent is given when the client cooperates through actions, such as holding out an arm to allow the nurse to perform the procedure. A client who has a distended bladder and needs urinary catheterization Implied consent is given when the client cooperates through actions, such as positioning herself to allow the nurse to perform the procedure.
A nurse is assessing a patient who reports increased pain after physical therapy. Which question shuld the nurse ask when assessing quality of client's pain?
A. "Is your pain constant or intermittent?" (onset and duration of pain) B. "What would you rate your pain on a scale of 0 to 10?" (intensity of pain) C. "Does the pain radiate?" (pain pattern) D. "Is your pain sharp or dull?" (wuality of pain can be sharp, dull, crushing, throbbing, electric, aching, burning, shotting)
A nurse is caring for client with heart murmur. The nurse is preparing to auscultate pulmonary valve. Over which location shuld the nurse place the bell of the stethescope?
A. 2nd intercostal space at left sternal border (nurse must listen over this location for pulmonary valve then listen to apex and other valve areas for heart rate, rhythm, gallops and murmurs) B. 4th intercostal space at right sternal border C. 4th intercostal space at left sternal border (indicates tricuspid valve) D. 2nd intercostal space at right sternal border (indicates aortic valve)
A home health nurse attends training session for therapeutic use of aromatherapy with essential oils is planning to use this with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
A. A client who has a history of physical abuse (Mental-health issues such as hx of physical abuse that affect sensitivity to touch are contraindicative for therapeutic touch) B. A client who has a permanent pacemaker (an implanted electrical device is contraindicative for magnet therapy) C. A client who has ulcerative colitis (Ulcerative colitis is a contraindicative for colonic detox) D. A client who has asthma (some essential oils can cause bronchospasm and should not be used with asthma pts)
A nurse working in ER is witnessing the signing of informed consent forms for treatment of multiple clients during her shift. Which individuals signatures may the nurse legally witness?
A. A teacher who brings in a 7-year-old student (incorrect as only a parent, legal guardian, or, grandparent or adult sibling in emergencies can legally give consent for treatment of young child) B. A 16-year-old client who is married is correct (correct - a married minor who is emancipated can give consent for personal treatment) C. A 27-year-old client who has schizophrenia (correct - adult client who requires psychiatric care can give consent for personal care unless court determined to be incompetent) D. An adoptive parent who brings in his 8-year-old son (correct.- adoptive parent is a legal guardian and can give consent for child's care) E. A 17-year-old mother who brings in her toddler i(correct - custodial parent, even minor, can legally give consent for treatment of her child)
A non-ambulatory client notifies the nurse that his trash can is on fire. After the nurse confirms the fire, the nurse should
A. Activate emergency fire alarm B. Extinguish the fire. C. Evacuate the client. MY ANSWER According to the RACE mnemonic, the first action in response to a fire is to Confine the fire. According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire. Remember "RACE" in response to fire; R - Rescue patient and move them to safe area A - Activate alarm C - Contain fire by closing all doors and windows, and turning off oxygen and electrical equipment in the area E - Extinguish or attempt to extinguish the fire
Nurse on surgical unit is receiving a client who had abdominal surgery from postanesthesia care unit. Which assessment should nurse make first?
ABC priority framework - first assess airway patency (ABC priority), assess breathing ability, and assess circulation or perfusion - assess pain level of a client - assess hydration status - assess urinary output
Nurse reviewing correct use of fire extinguisher with a client. Which action sshould nurse direct the clietn to take first?
Aim the hose at the base of the fire. Evidenced-based practice indicates aiming the hose of the fire extinguisher is the second step the client should take. Squeeze the handle of the extinguisher. Evidenced-based practice indicates squeezing the handle of the extinguisher is the third step the client should take. Remove the safety pin from the extinguisher. MY ANSWER Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first. Sweep the hose from side to side to dispense material. Evidenced-based practice indicates sweeping the hose from side to side to dispense material is the fourth step the client should take.
Nurse is caring for 48 hour post-op patient following small bowel resection. Client reports gas pain in periumbilical area and nurse plan of care should be based on which factor that contributes to this post-op complication?
Blood loss Blood loss can cause shock but it does not contribute to the findings demonstrated by this client. NPO status after surgery NPO status after surgery can cause dehydration but it does not contribute to the findings demonstrated by this client. Nasogastric tube suctioning Nasogastric tube suctioning keeps the stomach and intestines decompressed and can help prevent the findings demonstrated by this client. Impaired peristalsis of the intestines MY ANSWER Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis.
Nurse is teaching PT post-op how to use flow oriented incentive spirometer. Which instruction should nurse include?
Blow into the spirometer to elevate the balls in the device. The nurse should instruct the client to inhale deeply to elevate the balls in the device. Cough deeply after each use. MY ANSWER Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs. Clean the mouth piece with an alcohol swab after each use. The nurse should instruct the client to clean the mouth piece with water and dry it after each use. Use the spirometer every 8 hr. The nurse should instruct the client to use the spirometer several times every hour while awake.
brainstem (medulla and pons) = difficulty breathing as this serves as respiratory control center hypothalamus = difficulty sleeping as this serves as center for secreting hypocretins which promote REM cerebral cortex = difficulty with expression as this area contains neural network of behavior, learning, memory, language cerebellum = difficulty balancing and muscle coordination
Brain Injuries
Nurse is providing teaching about food choices to clietn with prescription for clear liquid diet. Which selection indicates understanding of the teaching by the client?
Cream of rice Cream of rice is allowed on a full liquid diet. Cottage cheese Cottage cheese is allowed on a soft diet. Gelatin MY ANSWER Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature. Ice cream Ice cream is allowed on a full liquid diet.
- drop medication in outer 1/3 of lower conjunctival sac - apply gentle pressure to nasolacrimal duct for 30-60 sec to keep medication from running out of eye - hold eyedropper 1-2 inches from lower sac - instruct client to close eyes gently when applying ointment or liquid to distribute medication
Instilling Eye drops
Assist Feeding for Bilateral Cast
Sit at the bedside while feeding the client. served appropriate texture and variety of foods; Puree for clients who cannot chew, have difficulty swallowing, or do not have teeth Make sure feedings are at preferred client temperature Offer a drink of fluid after each bite;if unable to communicate offer fluids x 3-4 mouthfuls
A nurse caring for older adult client who is violent and attamps to disconnect IV lines. The provider prescribes soft wrist restraints. Which action should the nurse take while the client is in restraints?
Tie the restraints to the side rails. The nurse should not tie the restraints to the side rails because this can injure the client if the rails are lowered. Perform range-of-motion exercises to the wrists every 3 hr. The nurse should ensure that the restraints are removed and range-of-motion exercises are performed every 2 hr. Remove the restraints one at a time. The nurse should remove one restraint at a time for a client who is violent or noncompliant. Obtain a PRN prescription for the restaints. MY ANSWER Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.
Nurse is performing neurological assessment on client. Which exmaination should nurse use to check patient's balance?
Two-point discrimination test by touching skin with 2 sharp pointed objects to determine if client can determine between two points Glasgow coma scale used to measure a client's level of consciousness. Babinski reflex is tested by using an object to strike sole of the foot and if toes spread outward = (+) result but if toes bend = (-) result Romberg test instructs the client to stand with feet together and arms at sides, first with his eyes open and then with eyes closed to test balance in which an inability to maintain balance is = (+) result
Nurse in provider's office is reviewing lab findings of client who reported chills and aching joints. The nurse should identify which finding as indication of infection?
WBC 15,000 mm3 MY ANSWER This finding is above the expected reference range and is an indication of infection. Erythrocyte sedimentation rate (ESR) 15 mm/hr Although an elevated ESR can indicate an infection, this finding is within the expected reference range. Urine pH 7.2 A urine pH of 7.2 is within the expected reference range. Urine specific gravity 1.0063 A urine specific gravity of 1.0063 is within the expected reference range.
A nurse is calculating a client's flud intake over past 8 hours. Which of the following items should hte nurse plan to document on I/O record as 120 mL of fluid?
2 cups of soup (= 480 mL) 1 quart of water (= 946 mL) 8 oz of ice chips (account for air between ice chips so 8 oz ice = 4 oz of liquid = 120 mL) 6 oz of tea (=180 mL) 1 oz = 30 mL
1 lb of body fat
3500 calories
Nurse is teaching an older client with constipation. Which statement should the nurse include in the teaching?
"Drink a minimum of 1,000 milliliters of fluid daily." The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation. "Increase your intake of refined-fiber foods." MY ANSWER The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods. "Sit on the toilet 30 minutes after eating a meal." Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. "Take a laxative every day to maintain regularity." The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.
Nurse is teaching client with lower extremity weakness how to use 4 point crutch gait. Which instruction should nurse include in teaching?
"Support the majority of your weight on the axillae." Pressure on the axillae increases risk to underlying nerves, which could result in partial paralysis of the arms. "Keep your elbows extended." The client should keep his elbows flexed about 30°. "Bear weight on both of your legs." The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs. "Move both crutches forward at the same time." MY ANSWER The client should move each leg alternately with each opposite crutch so that three points of support are on the floor at all times.
Nurse on telemetry unit is caring for client with myocardial infarction. Client states "all this equipment is making me nervous". How should nurse respond?
"You won't need the equipment very long." (illustrates giving false reassurance) "All of this equipment can be frightening." (therapeutic response reflects the client's statement and shows understanding of feelings to encourage communication) "Why does the equipment bother you?" (requests explanation) "Let me tell you about what each machine does." (doesnt address client's concerns because nurse is changing subject)
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
A. check the client for injuries B. move haxardous objects away from the PT C. notify the provider D. ask the client to describe how she felt prior to the fall The priority action the nurse should take when using the nursing process is to assess the client for injuries. Secondary actions include moving hazardous objects away to prevent further injury, notifying the provider to inform him of the fall, and determining facts that surround the fall is important to help prevent subsequent falls;
Manifestations of Abnormal Labs (Ca, K)
Hypocalcemia (Ca below 8.4) - assess by tapping facial nerve in front of client's ear and if twitching results = +Chvostek's Sign - associated with tetany and muscle spasms Hypercalcemia (Ca above 10.5) - assess for lethargy, weakness Hypokalemia (K+ below 3.5) and Hyperkalemia (K+ above 5.0) - assess for muscle weakness and cardiac arrhythmias
Nurse is applying ice bag to ankle of client following sports injury. Which action should nurse take?
Leave the bag in place for 45 min. To reduce the risk of injury to the to the client's skin, the nurse should leave the ice bag in place no longer than 30 min. Fill the bag two-thirds full with ice. The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle. Place the ice bag uncovered on the client's ankle. The nurse should cover the ice bag with a towel or other type of cover before placing the ice bag on the client's ankle to prevent injury to the client's skin. Tell the client that it is expected to feel numbness when the ice bag is in place. MY ANSWER The nurse should remove the ice bag if the client feels numbness because numbness is an indication that the client's skin is too cold and at risk for injury.
Nurse providing education about cultural and religious traditions and rituals related to death for AP on the unit. Which info should nurse include?
Organ donation is encouraged by people who are practicing Jehovah's Witnesses. Organ donation is prohibited by people who are practicing Jehovah's Witnesses. People who practice Roman Catholicism prefer cremation. Cremation is discouraged by people who practice Roman Catholicism. People who practice Judaism stay with the body of the deceased until burial. MY ANSWER In the Jewish faith, a family member often stays with the body until burial occurs. People who are practicing Christian Scientists believe in euthanasia. Some people who practice buddism believe in euthanasia.
A nurse is teaching an older adult PT who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
Regular Physical Exercise for Older Adult - walking briskly - weight bearing exercises to maintain bone mass - cycling and isometric exercises have no weight bearing advantages and do not prevent osteoporosis - high impact aerobics can injure bones with density loss therefore they are not recommended for osteoporosis patients
Nurse is providing teaching to client with heart failure about how to reduce daily sodium intake. Which factor is most important in determining client's ability to learn new dietary habits?
The involvement of the client in planning the change MY ANSWER According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits. The emphasis the provider places on the dietary changes The emphasis the provider places on the dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor. The learning theory the nurse uses to teach the dietary changes The learning theory the nurse uses to teach dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor. The extent of the dietary changes planned for the client The extent of the changes planned can influence the client's ability to learn new dietary habits; however, it is not the most important factor.
Blood Transfusion Reactions
hemolytic reaction occurs when client's blood is incompatible with donor's blood resulting in chills, low back pain, hypotension, tachycardia, reddish brown urine, flank pain febrile reaction occurs when client's blood is sensitive to WBCs and platelets found in donor blood resulting in fever, chills, headache, flushing Circulatory overload occurs when blood is administered too quickly and results in dyspnea, cough, headache, and hypertension Sepsis occurs when the blood is contaminated with bacteria and results in high fever, vomiting, and diarrhea
red coloration of skin in clients with light skin or blue coloration to dark skin
hyperemia
Prolonged Exposure to Stress
increases secretion of cortisol leading to - essential or primary hypertension -hyperglycemia - weakens the immune response - platelet aggregation -increase risk of MI and stroke
Erikson's Developmental Tasks
toddler - trust v mistrust school age children - industry v inferiority adolescence - identity v role ocnfusion young adulthood - intimacy v isolation middle adulthood - generativity v self absorption and stagnation
Nurse is initiating protective environment for client who had allogeneic stem cell transplant (immunocompromised). Which of the following precautions should the nurse plan?
Make sure the client's room has at least 6 air exchanges per hour (protective environment requires at least 12 air exchanges per hr) Make sure the client wears a mask when outside her room if there is construction in the area (patient is at increase risk for infection and will require protection from breathing in pathogens in the environment) Place the client in a private room with negative-pressure airflow (place client in a private room with positive-pressure airflow) Wear an N95 respirator when giving the client direct care (airborne precautions require the nurse to wear N95 respirator mask during direct PT care)
A nurse is assisting a post-op client with the use of incentive spirometer. Which position should the nurse place the client?
Semi or High Fowler's position allows maximal expansion of lungs. - side-lying, supine, Trendelenburg (head below feet) does not promote lung expansion
involves thick white patches in mucous membranes of mouth that can be precancerous and seen in patienst who smoke
leukoplakia
Nurse in LTC is admitting a client with incontinence and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. WHich response should the nurse make?
"A lot of clients who are cared for at home have the same problem." This response is an automatic response. It also implies that caregivers in the home are not able to keep clients odor-free. It is a judgmental statement that is not therapeutic. "Don't worry about it. He will get a bath, and that will take care of the odor." MY ANSWER Telling the partner not to worry blocks communication by devaluing her feelings and her concern about the odor. "It must be difficult to care for someone who is confined to bed." This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings. "When was the last time that he had a bath?" This response implies to the partner that the odor of urine developed because she has not bathed her husband for some time. This approach is judgmental and nontherapeutic.
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by the group indicates the teaching has been effective?
"I should expect my heart rate to take longer to return to normal after exercise as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise. "Urinary incontinence is something I will have to live with as I grow older." MY ANSWER Although bladder capacity decreases in older adults, urinary incontinence is not an expected finding and older adults should report incontinence so that it can be investigated and treated. "I can expect to have less ear wax as I get older." Older adults have an increased buildup of cerumen in the ears, which may increase expected incidence problems with hearing loss. "My stomach will empty more quickly after meals as I grow older." Decreased gastric emptying is an expected finding in older adults.
Nurse is caring for older adult client who becomes agigtated when nurse requests client's dentures be removed prior to surgery. Which action should nurse take?
"It's for your safety. Dentures can slip and block your airway during surgery." MY ANSWER This represents the nontherapeutic communication technique of ignoring or dismissing the client's feelings. It does not address the client's agitation. "You wouldn't want your teeth to be lost or broken during surgery, would you?" This represents the nontherapeutic communication technique of disagreeing with the client and offering unsolicited advice. It does not address the client's agitation. "The anesthesiologist requires everyone to remove their dentures." This represents the nontherapeutic communication technique of focusing on inappropriate issues or individuals (the anesthesiologist). It does not address the client's agitation. "What worries you about being without your teeth?" This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it.
Nurse caring for client with type 1 DM and is resistant to self-injection of insultin. Which statement should nurse make?
"Tell me what I can do to help you overcome your fear of giving yourself injections." MY ANSWER This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." This response illustrates the nontherapeutic communication technique of challenging the client and ignores the client's concern. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." This response illustrates the nontherapeutic communication technique of unwarranted reassurance and does not address the client's fears. "You won't be able to go home unless you learn to give yourself insulin injections." This response illustrates the nontherapeutic communication technique of threatening the client. This response will not help the client overcome his fears.
A nurse is teaching AP about proper hand hygiene. Which statement by AP indicates understanding of teaching?
"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." MY ANSWER While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. "I will use cold water when I wash my hands to protect my skin from becoming too dry." Hand hygiene should be performed with warm water. Warm water preserves the protective oil of the skin better than hot water. "I will apply friction for at least 10 seconds while washing my hands." Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds. "After washing my hands I will dry them from the elbows down." Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.
Fahrenheit to Celsius or Celsius to Fahrenheit
(F - 32)/1.8 (C x 1.8) + 32
Cleansing Enema Administration
- don clean (nonsterile) gloves -Position client on left side in Sim's position to allow solution to flow down to sigmoid and descending colon -lubricate 5-8 cm (2-3 inches) of tip before inserting -insert the rectal tube 7 to 10 cm (3 to 4 in) -hold solution bag 30 cm (12 in) above rectum for a low enema and 45 cm (18 in) for a high enema height of bag determines rate of solution and if too high, may cause spasms or contractions
tuberculin skin test.
- hand hygiene - use 25 to 27 gauge needle for intradermal injection - needle inserted 10-15 angle - do not massage area as this can spread medication into tissue circle injection area with pen to ensure reading results in correct site 48-72 hours later
A nurse is obtaining BP in lower extremity. Which action should the nurse take?
- place client in prone position if possible or lie in supine position with knee flexed - auscultate BP at popliteal artery - place cuff 2.5 cm or 1 inch above popliteal artery - place bladder of cuff over posterior thigh
Nurse is planning to perform passive ROM exercises.
- stand at the side of the bed closest to the joint being exercised. - move the joint to the point of slight resistance. - exercise larger joints first - repeat each joint motion 3-5 x per session
Nurse responding to parent's question about infant's expected physical development during 1st year of life. Which information should nurse include?
A 2-month-old infant can turn from his abdomen to his back. An infant cannot turn from his abdomen to his back until he is 5 months old. A 10-month-old infant can pull up to a standing position. An 8 to 10-month-old infant can pull himself to a standing position. A 4-month-old infant can sit up without support. A 6 to 8-month-old infant can sit up without support. A 6-month-old infant can crawl on his hands and knees. An 8 to 10-month-old infant can creep on his hands and knees.
A nurse is caring for a group of patients on med-surg. In which of the following situations does the nurse demonstrate the ethical princple of veracity?
A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. When stopping a procedure the client refuses, the nurse is following the ethical principle of autonomy and is recognizing the client's right to refuse treatment. A client with a do-not-resuscitate (DNR) status has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. If a provider has documented a DNR prescription in the client's medical record, the nurse must follow that directive. To avoid situations like this, the nurse should have open discussions with the client and family to make sure they understand the implications of the client's DNR status. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she would give her. MY ANSWER This is an example of the ethical principle of fidelity, which means keeping promises.
A nurse is caring for a patient with aggressive form of prostate cancer. The provider briefly discussed treatment options and left patient's room. When the nurse asks the patient if they would like to discuss any concerns, the patient declines. Which of the following statements should the nurse make?
A. "I will return shortly after I document this in your record." (although helpful to assure client that the nurse will return, reminding him about the need to perform certain tasks is likely to sound dismissive of his needs) B. "Most men live a long time with prostate cancer." (provides false reassurance. The nurse cannot predict what this client's outcome might be.) C . "I am available to talk if you should change your mind." (when a client does not wish to share feelings, its important that the nurse convey availability if the patient needs her) D. "I will make a referral to a cancer support group for you." (dismissing client's concerns by referring elsewhere without specific nursing interventions is nontherapeutic)
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements would indicate understanding of the teaching?
A. "when descending stairs, I will shift my weight to my right leg" (when going downstairs, client should first shift body weight to unaffected leg B. "I should place my crutches 12 inches in front and to the side of each foot" (place crutches 15 cm (6 in) in front and to the side of each foot.) C. "As I sit down, I will hold one crutch in each hand" (before sitting down, client should hold crutches by hand bars in one hand.) D. "I will make sure the shoulder rests are snug against my armpits" (shoulder rests should be at least 2.5-5 cm (1 to 2 in) below the axillae to avoid injury to nerves)
A nurse is caring for a group of patients. Which of the following actions should the nurse take to prevent spread of infection?
A. Carry a client's soiled linens out of the room in a mesh linen bag (place soiled linens in fluid-resistant bag) B. Place client with tuberculosis in a room with negative-pressure airflow (airborne precautions for tuberculosis which include negative-pressure airflow room to reduce risk of infection) C. Provide disposable plates and utensils for HIV+ client (standard precautions as HIV is transmitted via bodily fluids so disposable plates and utensils are not required D. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag (dispose items with large amount of blood in biohazard bag)
A nurse is caring for a client who requires CXR. Prior to transported to procedure, which action should the nurse take first?
A. Explain the x-ray procedure to the client. B. Help the client into a wheelchair before the transporter arrives. C. Ask if the client has any questions. D. Identify the client using two identifiers assess the client using Maslow's Hierarchy of Needs, ABC priority, or nursing knowledge to identify which risk poses the greatest threat which is the client's identity in which the nurse must assure that the correct client is being transported for a chest x-ray
A nurse is planning to initiate IV therapy for older adult client who requires IV fluids. Which of the following actions should the nurse take?
A. Insert the IV catheter into the back of the client's hand. (avoid areas of flexion such as hand because a catheter in that area may interfere with a PT's mobility and independence) B. Massage the area of the venipuncture site vigorously. (avoid as this may cause injury or skin tearing) C. Insert the IV catheter without using a tourniquet (correct - to avoid injurying fragile skin or veins) D. Apply traction to the skin proximal to the insertion site to stabilize the vein (apply traction to the skin DISTAL to the insertion site if veins roll)
Nurse using SBAR communication tool provides information about client to provider. Nurse should convey patient's pain status in which portion of the report?
Assessment MY ANSWER The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings. Background The nurse provides information about pertinent medical history, laboratory findings, allergies, and code status in this portion of the report. Situation The nurse provides information about problems the client is experiencing in this portion of the report. Recommendation The nurse makes recommendations about treatment and asks the provider about additional treatment in this portion of the report
Nurse is teaching client how to self-administer insulin. Which action should nurse take to evaluate client's understanding of the process within psychomotor domain of learning?
Ask the client if he wants to self-administer his insulin. Asking the client if he wants to self-administer his insulin evaluates the client's understanding within the affective domain of learning. Have the client list the steps of the procedure Having the client list the steps of the procedure evaluates the client's learning within the cognitive domain of learning. Have the client demonstrates the procedure. MY ANSWER Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning. Ask the client if he understands the purpose of insulin. Asking the client if he understands the purpose of insulin evaluates the client's understanding within the cognitive domain of learning.
Nurse on med-surg is admitting client. Which information should nurse document in record first?
Assessment MY ANSWER When caring for this client, the nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Plan of care The nurse should document the plan of care for the client. However, there is another action the nurse should document first. Nursing interventions performed The nurse should document interventions performed for the client. However, there is another action the nurse should document first. Evaluation of progress The nurse should document the evaluation of the client's progress. However, there is another action the nurse should document first.
Nurse is planning weight loss strategies for group of obese clients. Which actions by the nurse will improve client's committment to long term weight loss?
Attempt to increase the clients' self-motivation - important in improving a committment to acheiving goals, and increasing amount and speed of learning . Keep detailed records of each client's progress- helps client track individual progress, but does not improve progress toward goals Test client learning after each teaching session- determine whether outcomes are reached but does not affect commitment to the goal Avoid discussing areas that might cause client anxiety- anxiety interfere with learning and should be addressed early in the teaching process.
Nurse assessing heart sounds of client with developed chest pain that worsens on inspiration. Nurse auscultates high-pitched scratching sound during systole and diastole with dirphagm of stethescope positioned at left sternal border. Which following heart sound should nurse document?
Audible clicks heard in prosthetic valves murmurs have swishing, whistling sound caused by turbulent blood flow through valves which may indicate valvular disease - low frequency heard better with bell high frequency heard with diaphragm S3 is low-pitched sound after S2 dubb caused by rapid ventricular filling during diastole thats best heard over mitral area with the client lying on left side. -commonly heard in children and young adults - older adults and clients with heart disease - S3 indicates heart failure Pericardial friction rub is high-pitched scratching, grating, or squeaking sound heard at left sternal border - caused by pericardial inflammation -heard with pericarditis, MI, cardiac surgery or trauma, autoimmune issues - accompanied by worsening chest pain relieved by sitting up and leaning forward
Nurse is planning to document care provided to client. Which abrbeviation should nurse use?
BT for bedtime The nurse should avoid using this abbreviation because it can be mistaken for BID, which means twice daily. It is an error prone abbreviation. The nurse should use the word bedtime. SC for subcutaneously The nurse should avoid using this abbreviation because it can be mistaken for sublingual. It is an error prone abbreviation. The nurse should use subcut or subcutaneously. PC for after meals MY ANSWER The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation. HS for half-strength The nurse should avoid using this abbreviation because it can be mistaken for bedtime. It is an error prone abbreviation. The nurse should use half-strength or bedtime.
A nurse is teaching dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest the client to add to his diet?
Beef liver A 3-oz serving of beef liver contains 410 mg of cholesterol. Shellfish A 3-oz serving of shrimp contains 166 mg of cholesterol; 3-oz servings of oysters and clams each contain 50 to 60 mg of cholesterol. Egg yolks One egg yolk contains 213 mg of cholesterol. Avocados MY ANSWER Avocados contain no cholesterol. Plant foods contain no cholesterol; foods from animals contain cholesterol.
A nurse is teaching cardiopulmonary rescuscitation (CPR) to newly licensed nurses. Which action shuld the nurse teach as first response to CPR?
Call for assistance. The nurse should call for assistance by activating the emergency response team. However, there is another action the nurse should take first. Begin chest compressions. The nurse should begin chest compressions. However, there is another action the nurse should take first. Confirm unresponsiveness. MY ANSWER The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team. Give rescue breaths. The nurse should give rescue breaths. However, there is another action the nurse should take first.
A nurse is caring for a client with terminal illness. The client asks several questions about a nurse's religious beliefs related to death and dying. Which action should the nurse take?
Change the topic because the client is trying to divert attention from the illness to the nurse. Changing the subject is a nontherapeutic communication technique that will block development of open communication between the nurse and client. Encourage the client to express his thoughts about death and dying. MY ANSWER The nurse should recognize the client's need to talk about impending death, and encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate. Tell the client that religious beliefs are a personal matter. This closed-ended response is a nontherapeutic communication technique that will block the communication with this client. Offer to contact the client's minister or the facility's chaplain. This response places the client's issue on hold and could cause barriers to communication between the nurse and the client.
Nurse in office is collecting information on older adult client who reports hes been taking 500 mg/day of acetaminophen for severe joint pain. The nurse instructs the client that large doses of acetaminophen could cause which adverse effects?
Constipation Constipation is an adverse effect of opioid analgesics. Gastric ulcers Gastric ulcers are an adverse effect of aspirin and other nonselective NSAIDs. Respiratory depression Respiratory depression is an adverse effect of opioid analgesics. Liver damage MY ANSWER Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.
Newly licensed nurse is preparing to administer meds to client. THe nurse notes provider has prescribed medicaiton thats unfamiliar to her. Which action should nurse take?
Consult the medication reference book available on the unit. MY ANSWER A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit. Ask a more experienced nurse for information about the medication. Even if the more experienced nurse has knowledge of the medication, information from the source is not sufficient for the nurse to safely administer the medication. Call the client's provider and verify the prescription. There is no reason to believe that the medication prescription is in error; therefore, it is unnecessary for the nurse to confirm it with the provider. Ask the client if she takes this medication at home. Even if the client has knowledge of the medication, information from the client is not sufficient for the nurse to safely administer the medication.
Nurse caring for client in terminal cancer stage. Which action should nurse take when she observed client crying?
Contact the family and ask them to stay with the client. - nurse shifts responsibility Offer to call the client's minister - nurse uses the nontherapeutic communication by putting clients needs on hold and shifts responsiblity Sit and hold the client's hand - nurse uses the therapeutic communication of silence, touch, and offering of self Leave the room and allow the client to cry privately.-fails to acknowledge the client's distress.
Nurse caring for post-op client after abdominal surgery. Which action shuld take first after discovering that client's wound is eviscerated?
Cover the incision with a moist sterile dressing. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client. Have the client lie on his back with his knees flexed. The nurse should use this position to reduce pressure on the incision. However, the nurse should take another action first. Call the client's surgeon. MY ANSWER The nurse should notify the surgeon or direct a colleague to notify the surgeon while tending to the client's immediate need. However, the nurse should take another action first. Reassure the client. The nurse should respond to the client's emotional needs. However, the nurse should take another action first.
A nurse in office is assessing a client with heart failure. The client has gained weight since last visit and her ankles are edematous. Which finding is another clinical manifestation of fluid volume excess?
FLuid volume deficit Sunken eye balls Hypotension Poor skin turgor Fluid volume overload Bounding pulse
A nurse is caring for a post-op client with signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure client's vitals x 15 min and call him back in 1 hour. From legal perspective, which action should the nurse take next?
Document the provider's statement in the medical record. The nurse should document the provider's directions to have this information in the medical record for later reference; however, another action is the nurse's priority. Notify the nursing manager. MY ANSWER The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care is provided to the client. Consult the facility's risk manager. The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority. Complete an incident report. The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority.
Nurse is caring for post-op child following tonsillectomy. Which action should nurse take?
Encourage the child to cough frequently to clear congestion from anesthesia. The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding. Place a heating pad at the child's neck for comfort. The nurse should offer an ice collar, not a heating pad, to ease the child's pain. Administer analgesics to the child on a routine schedule throughout the day and night. To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route. Provide the child with ice cream when oral intake is initiated. MY ANSWER Milk products, such as ice cream and pudding, are usually avoided because they coat the mouth and throat, causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy.
Carminative - assist a client to expel flatus. Hypertonic - to cleanse client's bowels in preparation for surgery Oil retention - used prior to removal of fecal impaction to soften the stool and make procedure less painful Sodium polystyrene sulfate - used on client with very high levels of potassium
Enema Types and Uses
Nurse is admitting client with decreased circulation of left leg. Which action should nurse take first?
Evaluate pedal pulses. For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Obtain a medical history. The nurse should obtain the client's medical history. However, there is another action the nurse should take first. Measure vital signs. The nurse should obtain baseline vital signs. However, there is another action the nurse should take first. Assess for leg pain. MY ANSWER The nurse should assess the client for pain. However, there is another action the nurse should take first.
Nurse at screening clinic is assesing PT with history of heart murmur related to aortic valve stenosis. WHich anatomical area would nurse place stethescope to aucultate aortic valve?
Fifth intercostal space just medial to the midclavicular line The mitral valve is located in the fifth intercostal space just medial to the midclavicular line. Second intercostal space to the left of the sternum The pulmonic valve is located in the second intercostal space to the left of the sternum. Fifth intercostal space to the left of the sternum The tricuspid valve is located in the fifth intercostal space to the left of the sternum. Second intercostal space to the right of the sternum MY ANSWER The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.
A nurse is caring for post-op patient with paralytic ileus. Which of the following abdominal assessments should the nurse expect?
Frequent bowel sounds with flatus Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool. Absent bowel sounds with distention MY ANSWER Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended. Hyperactive bowel sounds with diarrhea Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool. Normal bowel sounds with increased peristalsis Paralytic ileus is an immobile bowel with decreased peristalsis. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.
A nurse is planning care for PT with abdominal pain. An assessment reveals temperature of 39.2 (102.6 F), HR 105/min, and soft non-tender abdomen, and menses overdue by 2 days. Which of the following findings is priority?
Heart rate 105/min This is an important assessment finding because the client's heart rate is elevated. However, fever and pain can contribute to tachycardia. This is not the priority finding. Soft, nontender abdomen This is an important assessment finding because of the client's report of pain. However, a soft nontender abdomen is an expected finding and should not cause concern. This is not the priority finding. Temperature MY ANSWER Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation. Overdue menses This is an important assessment finding because of the client's report of pain. However, an irregularity in the menstrual cycle is a common finding when a client is stressed. This is not the priority finding.
Community health nurse is preparing capaign about seasonal influenza. Which plan should nurse include as secondary prevention?
Holding a community clinic to administer influenza immunizations. MY ANSWER Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill. Screening groups of older adults in nursing care facilities for early influenza manifestations. Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe. Educating parents of young children about dangers of influenza. Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill. Finding rehabilitation programs for older adults who have complications from influenza. This is an example of tertiary prevention, which tries to prevent complications and help people recover from an existing illness.
Nurse on med-surg is caring for client. Which action should nurse take first when using nursing process?
Identify goals for client care. The nursing process is based on the scientific process. While identifying goals is an appropriate step in the nursing process, it is not the first step. Obtain client information. MY ANSWER The nursing process is based on the scientific process. The first step in the scientific process is the collection of data. Therefore, the first step in the nursing process is assessing and obtaining information about the client. Document nursing care needs. The nursing process is based on the scientific process. While documenting the client's care needs is an appropriate step in the nursing process, it is not the first step. Evaluate the effectiveness of care. The nursing process is based on the scientific process. While evaluating the effectiveness of the client's care is an appropriate step in the nursing process, it is not the first step.
IM injection sites
Infants and Children 1. priority site is the vastus lateralis or anterior thigh 5 months and up 2. ventrogluteal 7 months and up 3. deltoid muscle 18 months and up for injecting small volumes with slight risk due to nerves and arteries 4. do not use dorsogluteal site as its unsafe due to proximity to sciatic nerve and superior gluteal nerve and artery Adult 1. priority is ventrogluteal as safest site containing thick gluteal muscles without nerves or vessels 2. vastus lateralis is thick and away from major blood vessels and nerves 3. deltoid site is easy to access but muscle is so small, sometimes poorly developed and close to arteries and nerves 4. do not use dorsogluteal is close to sciatic nerve, superior gluteal nerve and superior artery
Nurse is planning to assess abdomen in client who reports feeling bloated for several weeks. Which method of assessment should nurse use first?
Inspection MY ANSWER According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps. Auscultation The nurse should auscultate the client's abdomen before percussion or palpation, both of which can stimulate peristalsis, yielding inaccurate results. This sequence is different from that of other body systems. Percussion The nurse should not percuss the client's abdomen first because percussion can cause pain and stimulate peristalsis, yielding inaccurate results in auscultation. Palpation The nurse should not palpate the client's abdomen first because palpation can cause pain and stimulate peristalsis, yielding inaccurate results in auscultation.
A nurse is receiving a client from PACU who is post-op following abdominal surgery. Which action should the nurse take to transfer the client from stretcher to bed?
Lock the wheels on the bed and stretcher (prevents injury to client from falling on floor) Instruct the client to raise his arms above his head(have client to cross his arms across chest to prevent injuring arms during transfer) Elevate stretcher 2.5 cm (1 in) above the height of the bed (elevate no more than 13 cm or 0.5 inches above the bed) Log roll the client. (used to move an immobilized patient of neck, back or spinal injury - not used for abdominal surgery)
Nurse on mental health unit is preparing to terminate nurse-client relationship with client who no longer requires care. Which concept should nurse discuss with client in termination phase of relationship?
Loss At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety. Trust The nurse should address the concept of trust during the introductory phase of the relationship. Self-disclosure MY ANSWER The nurse should address the concept of appropriate self-disclosure during the working phase of the relationship. Risk-taking The nurse should address the concept of risk-taking in the working phase of the nurse-client relationship.
Nurse measuring vital signs for client and notices irregular pulse. Which action should nurse take?
Measure the pulse using a Doppler ultrasound stethoscope. The nurse should use a Doppler ultrasound stethoscope for a pulse that is nonpalpable or very difficult to palpate. Check the client's pedal pulses. The nurse should assess pedal pulses to determine circulation in the client's lower extremities. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record. Take the pulse at each peripheral site and count the rate for 30 seconds. MY ANSWER The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.
- protein serves as energy source when carbs and fats are unavaiable or depleted - protein breaks down into amino acids and ammonia - carbs provide 4/cal of energy and fat provides 9 kal of energy Incomplete proteins - missing one or more essential amino acids - Cereal and other foods made from grains -peanut butter - pasta - Legumes (peas and beans) - gelatin - Nuts and seeds Complete Proteins - contain all 9 essential amino acids to maintain and promote wound healing, growth and homeostasis - cheese - poultry - fish - eggs - meat - milk -yogurt -soymean products Intake needed for wound healing calorie 35-40 kcal/kg of body weight fluid 30-35 mL/kg protein intake of 1-1.5 g/kg
Nutrition Teaching
Nurse taking care of a client while sitting in a chair starts to experience a seizure. Which action should nurse take?
Place a padded tongue blade in the client's mouth. The nurse should avoid placing a padded tongue blade in the client's mouth because this can cause injury, such as broken teeth. Lower the client to the floor and place a pad under the client's head. MY ANSWER To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head. Seek the help of a coworker and lift the client back into bed. The nurse should not attempt to lift the client while he is experiencing a seizure. Use an oropharyngeal airway to keep upper airway passages open. The nurse should avoid inserting an oropharyngeal airway because this can cause injury, such as broken teeth.
Nurse is preparing to provide chest physiotherapy for client with left lower lobe atelectasis (collapsed lung). Which action should nurse plan to take?
Place the client in Trendelenburg's position. The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe. Perform percussions directly over the client's bare skin. MY ANSWER The nurse should perform percussions over a single layer of clothing. Use a flattened hand to perform percussions. The nurse should use a cupped hand to provide percussions. Remind the client that chest percussions can cause mild pain. Chest percussions should not cause pain when the procedure is performed correctly.
Nurse in ER is assessing client who reports diarrhea and decreased urination for 4 days. Which action shuld nurse take to assess skin turgor?
Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. The nurse uses this technique for assessing capillary refill. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. MY ANSWER The nurse should use this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. The nurse uses this technique for determining how much pitting edema a client has. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers. The nurse uses this technique for determining a client's body fat percentage.
A nurse is planning to obtain vitals of 2 year old experiencing diarrhea and might have right ear infection. Which route should nurse obtain temperature?
Rectal The rectal route is very accurate for obtaining body temperature in young children; however, it should not be used for clients who have diarrhea. Tympanic The tympanic route can be used in young children, but should be avoided in a child who has an active ear infection or who has tympanostomy tubes in place. Oral The oral route is not appropriate for use with children under the age of 3. Temporal MY ANSWER The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.
Nurse caring for client receiving IV therapy via peripheral catheter. Which finding indicates infiltration?
Redness at the infusion site Redness at the infusion site is an indication of phlebitis or infection. Edema at the infusion site MY ANSWER Edema due to fluid entering subcutaneous tissue is an indication of infiltration. Warmth at the infusion site Warmth at the infusion site is an indication of phlebitis or infection. Oozing of blood at the infusion site Oozing of blood at the infusion site is an indication that the IV system is not intact.
pH, HCO3, PaCO2
Respiratory Alkalosis - pH above 7.45, PaCo2 below range (35, HCO3 within range (22-26) Respiratory Acidosis - pH below range (7.35, PaCo2 above 45, HCO3 within range (22-26) Metabolic Alkalosis - pH above 7.45, PaCo2 in range (35-45), HCO3 above 26 Metabolic Acidosis - pH below 7.35, PaCo2 in range (35-45), HCO3 below 22
A home health nurse is visiting an older adult client with severe dementia and meets the client's son who serves as primary caregiver and reports being exhausted from working part time and taking care of his mother at home. What service should the nurse suggest?
Respite Care - service for caregivers who need time to rest from responsiblities related to care of family member who needs assistance Rehabilitation programs - help clients return to obptimal functioning after illness or injury Assisted living facility- provides independence for clients who need only limited personal care adult day care facility- helps family caregivers maintain some lifestyle aspects and indepdnendce by providing care and supervison for clients who need minimal assistance (taking meds, physical therapy, counseling)
Nurse is providing discharge teaching to client recovering from lung cancer. The provider instructed client that he could resume lower intensity activities of daily living. Which activities should hte nurse recommend?
Sweeping the floor Sweeping the floor is a moderate-intensity activity. Shoveling snow Shoveling snow is a high-intensity activity. Cleaning windows Cleaning windows is a moderate-intensity activity. Washing dishes MY ANSWER Washing dishes requires a low level of activity and is appropriate for this client.
Home health nurse is planning health promotion activities for group of poeple in community. Which action is example of promoting primary prevention?
Teaching clients to perform self-examinations of breasts and testicles This activity is an example of secondary prevention. Secondary prevention focuses on measures that identify the early stages of a condition. Educating clients about the recommended immunization schedule for adults MY ANSWER Primary prevention includes health education about disease prevention. Teaching clients who have type 1 diabetes mellitus about care of the feet This activity is an example of tertiary prevention. Tertiary prevention occurs after diagnosis of a condition and the focus is to limit complications from the condition. Recommending that clients over the age of 50 have a fecal occult blood test annually This activity is an example of secondary prevention. Secondary prevention focuses on measures that identify the early stages of a condition.
Nurse is preparing client scheduled for hysterectomy for transport to operating room when client states she no longer wants to undergo surgery. Which action should nurse take?
Tell the client it is too late for her to change her mind because the surgery is already scheduled. The client has the right to refuse a procedure after giving consent. Telephone the operating room and cancel the surgery. This is not the responsibility of the nurse, but a decision the surgeon and the client must make. Inform the client's family about the situation. To respect the client's confidentiality, the family can be notified only after the client requests that the nurse do so. Notify the provider about the client's decision. MY ANSWER Acting as the client advocate, the nurse should support the client in her decision and notify the provider.
Nurse demonstrates post-op deep breathing and coughing exercises to client who will have emergency surgery of appendicitis. Which statement indicates a lack of readiness to learn by the client?
The client asks the nurse to repeat the instructions before attempting the exercises. Asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, he does have a readiness to learn the activity. The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity. The client asks the nurse how often deep breathing should be done after surgery. Asking about the frequency of the activity indicates a readiness to learn. The client is motivated to perform the activity and wants to know how often to do it. The client tells the nurse that this exercise will probably be painful after surgery. MY ANSWER The client's statement indicates to the nurse that the client has a readiness to learn because he is able to think about the possible effects of the exercise following surgery.
A nurse witnessing a client sign an informed consent for surgery. Which of the following describes what the nurse is affirming by this action?
The client fully understands the provider's explanation of the procedure. MY ANSWER It is the responsibility of the provider who will perform the procedure to ensure that the client understands the explanation of the procedure. The client has been informed about the risks and benefits of the procedure. It is the responsibility of the provider who will perform the procedure to inform the client about the risks and benefits and to obtain consent. The nurse witnessed the provider's explanation of the procedure. It is not necessary for the nurse to witness the provider's explanation of the procedure. The signature on the preoperative consent form is the client's. The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.
Nurse observes AP preparing to obtain BP with regular size cuff for obese client. Which explanation should nurse give teh AP?
The reading will be inaudible if the cuff is too small for the client." Although the blood pressure reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading. "The width of the cuff bladder should be 75% of the circumference of the client's arm." The width of the cuff bladder should be 40% of the circumference of the client's arm. "As long as the cuff will circle the arm the reading will be accurate." A cuff that is an incorrect size for the client will not yield an accurate reading. "Using a cuff that is too small will result in an inaccurately high reading." MY ANSWER Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.
Client is discharged home with oxygen therapy via nasal vannula. Which instruction should nurse provide?
Use battery-operated equipment for personal care. Electrical equipment in good condition with no frayed wires is acceptable for personal care when oxygen is administered. Apply mineral oil to protect the facial skin from irritation. Most oils and petroleum products are flammable when used on the body, which is a contraindication for their use because oxygen is a highly combustible gas. Remove the television set from the client's bedroom. As long as the television is in proper working order, there is no oxygen-related need to remove it from the client's bedroom. Wear cotton clothing to avoid static electricity. MY ANSWER The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.
A nurse is caring for unstable client with vital signs x 15 min by electronic BP machine. Nurse notices machine begins to measure blood presure at various intervals and readings are inconsitent. Which action should the nurse take?
Turn on the machine every 15 min to measure the client's blood pressure. Because the measurements and the operation of the machine appear questionable, operating the equipment differently cannot ensure the accuracy of the readings. The nurse should tag the machine and take it out of use. Record only blood pressure readings needed for the 15-min intervals. Although the equipment is obtaining blood pressure readings, the increased measurements and dissimilar results suggest that the machine is malfunctioning. Thus, all the readings are possibly inaccurate. The nurse should tag the machine and take it out of use. Obtain manual and automatic readings and compare them. MY ANSWER Although this option appears to provide a means of checking the machine, the fact that it is not operating correctly already suggests that the accuracy of the readings is questionable. The nurse should tag the machine and take it out of use. Disconnect the machine, and measure the blood pressure manually every 15 min. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.
What findings indicate that death is imminent?
Urinary retention or urinary incontinence Cold extremities first in the feet then in the hands Hypotension bradycardia thready pulse
A nurse is inserting IV catheter for client that results in blood spill on gloved hand. Client has no documented bloodstream infection. Which action should nurse take?
Wash the gloved hands and then throw the gloves away. Washing the hands while still gloved is not a recommended action. Prepare an incident report to document the event. Unless there is a break in the nurse's skin, there is no need for an incident report or further investigation. Carefully remove the gloves and follow with hand hygiene. MY ANSWER Standard precautions require the use of gloves and hand hygiene in the care of all clients. Ask the provider to order a blood culture to determine the risk of infection. Unless there is a break in the nurse's skin, there is no need for further investigation.
A nurse in provider's office is assessing deep tendon reflexes of a client. Which image should the nurse identify as indicating correct technique for eliciting client's patellar reflex?
hitting posterior ankle (nurse bends ankle backward slightly and taps achilles tendon at the ankle above the heel to assess Achilles Reflex & elicit plantar flexion) hitting anterior knee (nurse allows PT to hang freely over side of exam table while seated and tap on patellar tendon just below kneecap to assess Patellar Reflex & elicit lower leg extension hitting interior portion of forearm (nurse bends client's arm at elbow with palm facing down and tap on bicep tendon to assess Biceps Reflex & ellicit arm flexion at the elbow hitting exterior portion of forearm on elbow (nurse should hold patient's upper arm horizontally while allowing lower part of the arm to relax and tap the triceps tendon above the elbow and assess Triceps Reflex & elicit arm extension at the elbow
decrease in WBC puts client at risk for infection ex: 3600 WBC count
leukopenia
How to evaluate skin moisture when performing a physical exam
palpation; use touch to help detect unsuual or unexpected sensations including texture, temperature, masses, or moisture percussion; nurse locates organs or masses and determines dimensions auscultation; nurse listens to heart, lung and bowel sounds inspection; nurse observes visual variations from expected findings
Nurse is providing oral care for unconscious client. Which action should nurse take?
raise bed to Semi-Fowler's position and turn client's head to the side facing the nurse use a padded tongue blade to keep the client's mouth open. - check for presence of gag reflex to determine risk of spiration use soft bristled toothbrush with nonabrasive fluoride toothpaste Rinse the client's mouth withwater or alcohol-free mouth wash Cleanse the client's mucous membranes with foam swab because lemon-glycerin swabs dry and irritate the mouth and can damage the teeth
Types of Drainage
sanguineous - blood tinged drainage that contains large amounts of RBC that have escaped from damaged capillaries and entered plasma purulent - very thick exudate with presence of pus consisting of WBC, dead tissue debris, and dead/living bacteria serous - mostly serum exudate completely clear portion of blood that appears watery and contains very few cells
Wound Dressings
stage 2 pressure ulcer - hydrocolloid dressing to absorb exudate and product moist environment to facilitate healting and prevent maceration of surrounding skin stage 4 pressure ulcer - calcium alginate used for significant exudate and must be covered with secondary dressing unstage pressure ulcer - proteolytic enxyme is applied to facilitate debridgement and soften eschar clean moist wound - apply collagen to bring cells into wound, stop bleeding, and stimulate healing
Prevent back injuries by
stand as close as possible to reduce back strain bend at the knees and hips spread your feet wide apart use assistive device or assistance when over 35 lbs rest feet one at a time on foot rest when standing for long periods
Blood Transfusion Protocal
two nurses must verify client's ID number, client's name, ABO compatiblity, and Rh compatibility to prevent reactions due to human error
diuresis or polyuria - excretion of high volumes of urine caused by hormonal or metabolic imbalance, diuretic therapy for treating renal or cardio disorders retention - accumulation of urine in bladder as a result of incomplete emptying or cessation of ability to urinate oliguria - diminished urine output despite optimal fluid intake dysuria - painful or difficult urination as a result of UTI or injury
urine disorders
Breath sounds heard over periphery of major lung fields
vesicular sounds (soft, low pitch) bronchial sounds over trachea (high pitch, hollow, loud) rhonchi sounds over trachea and bronchi if secretions or inflammation narrow airways (gurgling) bronchovesicular sounds on either side of anterior sternal border and between posterior scapulae (moderate volume, medium pitch)
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore". Which of the following responses should the nurse make?
"Most people are happy when their children grow up and leave home." (automatic or stereotypical response that minimizes client's feelings by implying that he should be like everyone else) "You should be proud that your children are becoming independent. "(response conveys nurse's approval of people who are proud of their children's independence, as though that is the only acceptable behavior) "Maybe you should consider why you are feeling useless." (clients may interpret "why" questions as accusatory and cause mistrust and resentment because the nurse is asking for an explanation instead of acknowledging PT feelings) "People in middle adulthood often find satisfaction in nurturing and guiding young people." (according to Erik Erikson, middle adulthood is generativity vs self-absorption and stagnation with the focus of offering support and guidance to future generations, so the nurse should explore opportunities for the client to master this stage such as volunteering or mentoring young people)
A nurse is caring for a PT who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
- turn stocking inside out up to heel before applying - apply stockings in the morning before client gets out of bed - slide top of stocking up over calf all at once to lesson constrictive wrinkles - ensure there are no creases or wrinkles - if stocking is too long, apply another size stocking - remove stockings once per shift to assess circulation and skin integrity - wear stockings while sitting in chair to promote venous return and avoid crossing legs
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
- using trapeze bar to assist with repositioning and transfer helps to avoid friction and shearing caused by sliding up and down in bed which reduces the risk of pressure ulcers - consume balanced diet with adequate fluid intake (2-3 L/day) - less than 3 bowel movements per week indicates constipation and the need for intervention -pulse strength of +2 on lower extremities is norma Risks for Skin BReakdown - report any signs of erythema on pressure points - High Fowler's position places additional pressure on sacrum and heels - massage can cause capillary breakdown of subcutaneous tissue
A nurse has accepted a verbal prescription for 3 tenths of a miligram of Levothyroxine IV stat for a client who has Myxedema Coma. How should the nurse transcribe this medicaiton in the patient's MAR?
A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.
A post-op client verbalizes pain as 2 on pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands pre-op teaching about pain management?
A. "I think I should take my pain medication more often, since it is not controlling my pain." (2 out of 10 is mild therefore PT does not require analgesic meds) B. "Breathing faster will help me keep my mind off of the pain." (rapid breathing leads to hyperventilation while slow focused breathing leads to relaxing and may help manage pain) C. "It might help me to listen to music while I'm lying in bed." (listening to music is an effective non-pharmacological intervention to manage mild pain) D. "I don't want to walk today because I have some pain." (post-op patients must ambulate even if experiencing mild pain)
A nurse is caring for a client reporting pain. When documenting the quality of client's pain on initial assessment, the nurse hsould record which of the following statements?
A. "I'm having mild pain." B. "The pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "The pain makes me feel nauseous." The client is describing the severity of the pain. The nurse should also use a pain scale to specify the intensity of the client's pain. The client is describing the quality of the pain, which is how the pain feels in her own words. The client is describing a factor that aggravates the pain. The client is describing a manifestation that accompanies her pain.
A nurse is providing care to 4 patients. Which of the following situations requires the nurse to complete an incident report?
A. A nurse tied a client's restraint straps to the moveable part of the bed frame. B. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology. C. A nurse administers a medication to a client 30 min before the dose is due. D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should tie the client's restraint straps to the moveable part of the bed frame to prevent injury when the client or a staff member raises or lowers the bed. A client who has tuberculosis should wear a surgical mask when outside of her room to prevent the spread of infection. The nurse may administer a routine medication that is not time-critical to a client 1 to 2 hr before or after the time it is due. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents.
A nurse is caring for post-op client. When the nurse prepares to change the dressing, the client says "every time you change my bandage it hurts so much". Which intervention is priority action?
A. Encourage the client to relax and take deep breaths during the dressing change (relaxation can help reduce anxiety about the procedure, but is not priority) B. Educate the client about the importance of the dressing change to prevent infection (aids in understanging procedure rationale and can help client relax, but not priority) C. Assist the client to a comfortable position for the dressing change (can help the client relax, but is not priority) D. Administer pain medication 45 min before changing the client's dressing (priority action when using Maslow's Hierarchy of needs is to meet physiological need for comfort and pain relief so nurse must administer analgesic 30-60 min before changing dressing)
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the patient's plan of care?
A. Wrap blankets around all four sides of the bed (to provide padding and prevent injury) B. Apply restraints during seizure activity (increases risk of injury during seizure) C. Place the client in a supine position during seizure activity (turn client to side-lying position to prevent occlusion of airway by tongue and to allow secretions to flow out the side of the mouth) D Have a tongue depressor at the client's bedside. (Inserting any object into the mouth during seizure increases the risk for injury to mucous membranes of mouth and teeth)
A nurse is using an open irrigation technique to irrigate an indwelling urinary catheter. Which action should the nurse take?
Before Procedure - have client bear down gently to help visualize urinary meatus and relax external sphincter of females for insertion of catheter - insertion may feel uncomfortable and can ease discomfort of bladder distention - ask client to take slow deep breathe before insertion Procedure -cleanse perineal area with soap and water 3 x day - tape catheter to the inner thigh of a female or abdomen of male - place collection bag below bladder level - make sure there are no kinks in the tubing Findings - unusual odor to urine indicates infection - specific gravity of 1.035 indicates concentration - + ketones indicates sign of DM and poor glucose control - Bladder scan 525 mL indicates blockage in catheter and requires irrigation Irrigation Technique: - place the client in supine or dorsal recumbent position for maximal access - instill 30-40 mL of irrigation fluid with each flush - subtract amount of irrigant used from total urine output - use 30-50 mL syringe to perform open irrigation
A nurse is evaluating the client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
Cane Instructions - keep 2 points of support on ground at all times (both feet or foot and crane) - top of cane should be parallel to greater trochanter - hold cane on unaffected or stronger side - elbow should be slightly flexed - advance cane then follow with with unaffected leg - support weight on both legs when moving cane forward - place cane 15-30 cm (6-12 inches) to the side of the foot
A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
Complications of Immobility -swelling, redness and tenderness in calf muscle may indicate thrombophlebitis - bladder distention indicates urinary retention due to loss of muscle tone and detrusor muscles in bladder - hypoventilation, hypoxia, hypercapnia = respiratory acidosis (low pH, CO2 above 45) - decreased peristalsis and intestinal motility = decreased bowel sounds may indicate constipation - decreased cardiac output, decreased BP, and tachycardia - hypercalcemia as bones demineralize from a lack of weight bearing exercise and excess calcium is deposited into joints causing stiffness and pain
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer. I should have a routine screening. What does that involve? Which of the following responses should the nurse make?
Detection/Screenings for Colorectal Cancer - average risks begin at age 50 - double-contrast barium enema x 5 yrs - colonoscopy x 10 yrs - fecal occult blood test annually - flexible sigmoidoscopy x 5 yrs - blood tests do not detect colorectal cancer
A nurse is administering 1 L of 0.9% sodium chloride to post-op client with fluid deficit. Which of the following changes indicate treatment was successful?
Increase in hematocrit Increase in respiratory rate Decrease in heart rate Decrease in capillary refill time Fluid Vol. Deficit = - increase in hematocrit due to depletion of extracellular fluid (over 47% for females, or over 52% for males) - tachypnea (more than 20 breaths/min) - slows capillary refill (longer than 3 sec) - tachycardia (over 100 bpm)
A nurse enters a client's room and finds her on the floor. The client's roomate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?
A. "Incident report completed" (incident report is a document part of risk management system used to protect healthcare facilities from litigation and is not included in the patient's medical record) B. "Client climbed over the bedrails" (nurse did not witness this event so it is not objective) C. "client found lying on the floor" (nurse witnessed this event and must document descriptively including objective info without any judgement or opinion about motive or cause) D. "client was trying to get out of bed" (nurse did not witness this so it is not objective)
A nurse is caring for a client who asks about the purpose of advanced directives. Which statement should the nurse make in response?
A. "They allow the court to overrule an adult client's refusal of medical treatment." B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." C. "They permit a client to withhold medical information from health care personnel." D. "They allow health care personnel in the emergency department to stabilize a client's condition." A court can only overrule an adult client's refusal of medical treatment if the client is legally incompetent. Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness. Americans with Disabilities Act, not advance directives, protects the privacy of a client who chooses not to disclose a medical disability. Emergency Medical Treatment and Active Labor Act, not advance directives, permits emergency personnel to provide care in the event of an emergency medical situation.
A nurse is caring for a PT who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of the assistive device?
A. "This type of hearing aid does not allow for fine tuning of volume." (behind the ear hearing aid allows fine tuning of volume so its useful in PTs with moderate-severe hearing loss) B. "I shouldn't have trouble keeping the hearing aid in place during exercise." (physical activity can dislodge the hearing aid easily) C. "I expect to hear a whistling sound when I first insert the hearing aid." (whistling indicates that the hearing aid does not fit properly or a build up of cerumen or fluid in the ear D. "I will be sure to remove my hearing aid before taking a shower." (water exposure will damage the hearing aid so its important to remove the hearing aid before showering)
A nurse is caring for a terminally ill client. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?
A. "We are not worried. We still have hope that everything will be okay." B. "This is a difficult time, but we are helping each other through this." C. "After he comes home, we can plan our family reunion." D. "We don't need to talk about funeral arrangements at this time." This statement reflects false hope and possibly denial of the terminal nature of the client's illness. An effective coping strategy is talking with others in the family and supporting each other. This statement displays effective coping skills because the family is using social supports to assist them throughout the grief process. This statement reflects false hope and possibly denial of the terminal nature of the client's illness This statement reflects an inability or unwillingness to face challenges that a family must go through when one of its members has a terminal illness.
A nurse is caring for a client with terminal diagnosis and whose health is declining. The client requests info about advanced directives. Which of the following responses should the nurse make?
A. "We can talk about advance directives, and I can also give you some brochures about them." (nurse offers info the client needs in a direct and simple way) B. "You should set up a time to talk with your provider about that." (nurse is dismissive and passing responsibility to the provider) C. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." (nurse is rejecting client's needs by postponing the discussion) D. "Why do you want to discuss this without your partner here to plan this with you?" (clients might interpret "why" questions as accusatory, and this may provoke feelings of mistrust and resentment)
A nurse is educating a patient with terminal illness about her request to decline resuscitation in living will. Client asks what dould happen if she arrived at ER and had difficulty breathing. Which of the following responses should the nurse provide?
A. "We will determine who the durable power of attorney for health care form has designated." (staff must honor living will so durable power of attorney is unnecessary) B. "We will apply oxygen through a tube in your nose." (supplemental oxygen via nasal cannula provides comfort and is not resuscitative) C. "We will ask if you have changed your mind." (advance directives are decided ahead of time to guide decision making during an event, and if client wants a change it will be honored but otherwise staff must honor whats documented) D. "We will insert a breathing tube while we evaluate your condition." (Intubation is a resuscitative measure)
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?" The client's terminal illness might prompt him to review his life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him. The basis of medicine is science, not spirituality. This statement does not reflect the client's conflict with spiritual beliefs. This statement reflects conflict in family relationships, not with the client's spiritual beliefs. This statement reflects the client's feelings of powerlessness but does not indicate a conflict of a spiritual nature.
A nurse in LTC facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
A. "When do you usually bathe, in the morning or in the evening?" B. "Do you prefer a bath or a shower?" C. "At what temperature do you prefer your bath water?" D. "Are you able to help with your hygiene care?" The nurse should determine the client's usual routines because following them can enhance the client's comfort. It also gives the client choices to help preserve her self-esteem; however, another assessment is the priority. The nurse should determine the client's preference for bathing because following that routine helps promote the client's comfort and independence. It also gives the client choices to help preserve her self-esteem; however, another assessment is the priority. The nurse should determine the client's preference for the bath water temperature to promote the client's comfort. It also gives the client choices to help preserve her self-esteem; however, another assessment is the priority. The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, the nurse's priority is to assess the client's ability to assist with her hygiene care.
A nurse is preparing to administer Enoxaparin Sq to a client. Which of the following actions should the nurse take?
A. Administer the medication with the needle at a 45° angle. (SQ injections require needle insertion at 45° to 90° angle) B. Administer the medication into the client's nondominant arm. (Enoxaparin [Lovenox] is administered into love handles or abdomen atleast 5 cm (2 in) from umbilicus) C. Pull the client's skin laterally or downward prior to administration. (Z-track technique is used for IM injections) D. Massage the injection site after administration (massaging iinjection site after anticoagulant [Lovenox /Enoxaparin] could increase the risk of bruising)
A nurse is giving change of shift report about a client admitted earlier in the day who has pneumonia. Which of the following peices of information is priority for the nurse to provide?
A. Admitting diagnosis (essential for planning care and following critical pathways but not priority) B. Breath sounds (priority when using ABC or airway, breathing, circulation approach to client care) C. Body temperature (essential for planning care and following critical pathways; but not priority) D. diagnostic test results (essential for planning care and following critical pathways, but not priority)
A nurse is reviewing medical records of client with pressure ulcer. Which of the following findings should the nurse expect?
A. Albumin level of 3 g/dL (normal range 3.5-5 so a level below 3.5 g/dL indicates protein deficiency and puts PT at risk for pressure ulcer formation and poor wound healing) B. HDL level of 90 mg/dL (high-density lipoprotein above 60 mg/dL is good and indicates protection against CAD) C. Norton scale score of 18 (a score of 16 or less would indicate pressure ulcer risk based on physical condition, mental condition, activity, mobility, and incontinence) D. Braden scale score of 20 (a score below 18 would indicate pressure ulcer risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear)
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the transfusion. Which of the following actions should the nurse take?
A. Ask the client to consider a direct donation. B. Withhold the blood transfusion. C. Request a consultation with the ethics committee. D. Ask the client's family to intervene. A direct donation still requires a blood transfusion and does not respect the client's choice. The principle of autonomy ensures that a client who is competent has the right to refuse treatment. A client who is competent has the right to refuse treatment, regardless of the consequences. There is no need to involve the ethics committee. Clients who are competent have the right to consent to or refuse treatment.
A charge nurse is discussing the responsiblity of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
A. Assign the client to a room with a negative air-flow system. B. Use alcohol-based hand sanitizer when leaving the client's room. C. Clean contaminated surfaces in the client's room with a phenol solution D. Have family members wear a gown and gloves when visiting. A client who has a Clostridium difficile infection requires a private room, but a negative air-flow system is not necessary. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, it does not kill Clostridium difficile spores. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves.
A nurse is caring for post-op patient following knee arthroplasty and requires the use of thigh-length sequential compression device. Which of the following actions should the nurse take?
A. Assist the client into a prone position (place client in a dorsal recumbent or Semi-Fowler's to apply the sleeves) B. Place a sleeve over the top of each leg with the opening at the knee (place sleeve under each leg with opening at the knee and then wrap the sleeve around the leg so its secure) C. Make sure two fingers can fit under the sleeves (if there is less than 2 finger spaces between the sleeves, inflatation may inhibit or impair circulation of the legs from being too tight) D. Set the ankle pressure at 65 mm Hg (set ankle pressure between 35-55 mm Hg to prevent skin damage and impaired circulation)
A nurse in a surgical suite notes documentation on a PT's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
A. Ensure sterilization of nondisposable items with ethylene oxide. B. Wrap monitoring cords with stockinette and tape them in place. C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. D. Wear hypoallergenic latex gloves that contain powder. Ethylene oxide can cause an allergic reaction in clients who have a latex allergy. The nurse should rinse any items that had this type of sterilization before use. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. The nurse should use a stopcock for injecting medication. Cleansing a latex item will not remove the latex protein. "Hypoallergenic" latex gloves contain latex and can still provoke an allergic response. Powder is especially harmful because it contains the latex protein. The nurse should make sure all members of the client-care staff wear nonlatex gloves.
A nurse is caring for a child with Rx for blood transfusion. The parents refused treatment due to religious beliefs. Which of the following actions should the nurse take?
A. Examine personal values about the issue (correct -nurse should examine personal values about the issue to help provide care without bias) B. Tell the parents that this is a necessary procedure (nurse should provide info about the procedure; however, telling the parents that it is necessary is disregarding parents' beliefs) C. Inform the parents that the staff does not require their consent (Parents must give consent for a child to receive a blood transfusion) D. Contact a spiritual support person to explain importance of procedure (nurse should provide infor about procedure; however, it is not appropriate to contact a spiritual support person without parental consent)
A nurse is caring for a PT with diarrhea due to shigella. Which of the following precautions should the nurse take?
A. Have the client wear a mask when receiving visitors. (client does not need to wear a mask because shigella does not require airborne or droplet precautions.) B. Wash her hands before and after contact with the client. (contact precautions and standard precautions) C. Assign the client to a room with negative-pressure airflow exchange.(assign client to private room, but not a negative-pressure room because shigella is not airborne) D. Instruct all visitors to limit their time with the client. (limiting visitors doesnt decrease the risk of shigella and it would increase a patients risk for depression and loneliness so encourage visitors)
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
A. Insert an implanted port. B. Close a laceration with sutures. C. Place an endotracheal tube. D .Initiate an enteral feeding through a gastrostomy tube. Implanted ports and other central venous access devices require insertion by a physician or an advanced practice nurse. Surgeons and other physicians close wounds with sutures. Physicians and clinicians with special training insert endotracheal tubes. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.
A nurse is caring for a client with respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning?
A. Insert the suction catheter while the client is swallowing (insert suction catheter while PT is inhaling to prevent insertion into esophagus) B. Apply intermittent suction when withdrawing the catheter (intermittent suction when withdrawing prevent injury to the mucosa as continuous suctioning for more than 10 sec can lead to cardiopulmonary complications) C. Place the catheter in a location that is clean and dry for later use (discard after use to eliminate risk of pathogens inrespiratory tract) D. Hold the suction catheter with her clean, nondominant hand (hold suction catheter with sterile dominant hand)
A nurse is performing peripheral vascular assessment for a client. When placing the bell of the stethescope on the client's neck, she hears whooshing sound which wuld indicate the following?
A. Narrowed arterial lumen B. Distended jugular veins C. Impaired ventricular contraction D. Asynchronous closure of the aortic and pulmonic valves narrowed arterial lumen or occluded arterial lumen create blowing sounds when blood is flowing through called Arterial bruits there is no sound to indicate blood flowing through distended jugular veins Impaired ventricular contraction produces extra heart sound heard as either S3 or S4. Asynchronous closure of the aortic and pulmonic valves is known as "splitting" of S2 and this results in hearing 2 dub sounds
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply
A. Place the client in a room with negative-pressure airflow. B. Wear gloves when assisting the client with oral care. C. Limit each visitor to 2-hr increments. D. Wear a surgical mask when providing client care. E Use antimicrobial sanitizer for hand hygiene. TB must use airborne precautions which include 1. Place the client in a room with negative-pressure airflow 2. Wear gloves when assisting the client with oral care (standard precautions whenever in contact with bodily fluids) 3. nurse does not need to limit the client's visitors, but nurse should require PT to wear surgical mask when outside the room and limit leaving the room to prevent spread of infection 4. nurse must wear an N95 mask when providing client care 5. Use antimicrobial sanitizer for hand hygiene and the nurse should wash her hands with soap and water when visibly soiled
A nurse is caring for a client with limited mobility of the lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
A. Place the client in high-Fowler's position (this puts additional pressure on sacrum and heels) B. Increase the carb intake (helps with tissue repair) C. Massage reddened areas with unscented lotion (causes capillary breakdown in SQ) D. Have the client use a trapeze bar when changing position (avoids friction and shearing)
A nurse is planning care for a patient with fluid overload. Which of the following actions should the nurse plan to take first?
A. Reduce dietary sodium (intervention to decrease fluid retention) B. Administer a loop diuretic. (intervention to prevent rapid progression of pulmonary edema) C. Evaluate electrolytes. (assessment needed to plan interventions according to lab results including Na+, K+, BUN, Hgb, Hct, protein) D. Restrict intake of oral fluids.(intervention to minimize severity of fluid overload) Follow ADPIE* in which Assessment is First Priority before planning Interventions
A nurse is reviewing evidence based practice principles about oxygen therapy administration with a newly licensed nurse. Which of the following actions should the nurse include?
A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter (regulate oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter) B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min (flow rate 1-6 L/min via nasal cannula as rates above 6 will cause clients to swallow air without increasing amount of oxygen inhaled (FiO2). C. Make sure the reservoir bag of a partial rebreathing mask remains deflated (reservoir bag should inflate 1/3 to 1/2 with inspiration and if it remains deflated this indicates too much carbon dioxide being exhaled (hypocapnia) D. Use petroleum jelly to lubricate the client's nares, face, and lips (use water-soluble lubricant to protect client's skin from the drying)
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs initial assessment, he notes that the client received only 80 mL over last 2 hours. Which of the following actions should the nurse take first?
A. Reposition the client (helps improve flow rate) B. Document the client's IV intake in the medical record (helps interprofessional team prevent or correct fluid imbalance) C. Request a new IV fluid prescription (to compensate for lost fluid intake) D. Check IV tubing for obstruction (first action the nurse should take is to assess the client and check IV tubing for obstruction to facilitate the flow of fluid through tubing and re-establish infusion rate prescribed)
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?
A. Rock the client up to a standing position. (used to generate patient momentum and reduce nurse's workload when lifting a client off the bed, but this is not priority) B. Pivot on the foot that is the farthest from the chair (used to give client room to move and nurse may also use other knee to support client's weak leg during transfer, but this is not priority) C. Assess the client for orthostatic hypotension (priority assessment for fall risk is to assess PT while sitting on edge of bed with feet dangling for dizziness and drop in BP before standing for transfer to chair) D. Apply a gait belt to the client (used to help maintain client's stability, but not a priority action)
A nurse is talking with a partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsiblities while caring for the partner. The nurse should identify that he is going through which of the following types of role-performance stress?
A. Role ambiguity (a person is unclear about role expectations in a given situation) B. Sick role (a person with alteration in health) C. Role overload (a person has more responsiblities than one person can perform) D. Role conflict (a person must assume opposing roles with incompatible expectations)
A nurse on a medical unit is preparing to discharge a client home. Which of the following actions should the nurse take as part of the medication reconciliation process?
A. Seal unused hospital medications in a plastic bag. (nurse does not handle client medication during reconciliation process) B. Evaluate the client's ability to self-administer medications. (nurse does not evaluate client's self-administration capabilities during reconciliation) C. Report an identified discrepancy to The Joint Commission. (might require tracking of identified discrepancies but reporting this incident is not part of the reconciliation process for individual client) D. Compare prescriptions with medications the client received during hospitalization. medication reconciliation - assess and document patient's MAR to create a current, accurate list of every medication the client is or should be taking - compare medications received with those newly prescribed to identify and address duplication or omission of medications and check for possible interactions - address and correct any discrepancies in medications to clarify information for PT in writing about which medications to take
A nurse is caring for a client who has terminal illness and is approaching death. The client's respirations are noisy from secretions in the airway and she is short of breath. Which of the following actions should the nurse take?
A. Turn the client every 4 hr (incorrect - turn x 2 hours or more frequently to break up secretions and prevent noisy respirations) B. Elevate the head of the client's bed (correct as it promotes postural drainage and allows chest expansion making it easier for PT to breathe and decrease noisy respirations) C. Hold oral care (incorrect - provide frequent oral care to keep PT mouth moist and comfort) D. Increase the room's temperature. (keep air temperature cool and allow air to circulate with fan or open windows is comfortable to dying PT and will decrease air hunger)
A nurse manager is overseeing care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPPA guidelines?
A. a nurse caring for a client reviews the medical chart with nursing student who is working with the nurse B. a nurse asks a nurse from another unit to assist with documentation C. A nurse who is caring for a PT returns a call to the PT's durable power of attorney for health care designee to discuss the PT's care D. a nurse discusses a client's status with the physical therapist that is caring for the PT at bedside Any health care professional directly caring for a client has access to medical information; therefore, this is not a violation of HIPAA guidelines. Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPAA guidelines. The person the durable power of attorney for health care designates has a legal right to information about the client's care; therefore, this is not a violation of HIPAA guidelines.
A nurse is planning an education session for an older adult client who has just learned that she has Type 2 Diabetes Mellitus. Which of the following strategies should the nurse plan to use with this client?
A. allow extra time for the PT to respond to questions B. expect the client to have difficulty understanding information C. avoid references to the PT's past experiences D keep the learning session private and one-on-one Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information. Cognitive abilities vary between individuals. Rather than expecting misunderstanding, the nurse should assess the client's cognition and ability to learn, teach accordingly, and verify understanding. The nurse should explore the client's past experiences and use them to establish connections to new knowledge. It is helpful when working with older adult clients to invite another household member to the teaching session so that person can help reinforce new information later. The nurse should also honor the client's preference for either one-on-one or group settings..
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply)
A. check the cord routinely for frays/tears B. keep unit atleast 4 ft away from gas stove C. consider purchasing generator for power backup D. observe for signs of hypoxia E. select synethetic clothing and bedding Safe use of oxygen therapy at home includes - cotton clothing and bedding to prevent static electricity - purchase of back up generator or getting on priority listing to restore power if an outage occurs - check cords routinely for frays or tears - keep equipment atleast 10 ft away from open flames (smoking, gas stove, fireplace) - observe for signs of hypoxia (anxiety, worsening fatigue, dizziness, rapid HR, increase RR, pallor, cyanosis) as this indicates a worsening condition
A nurse is auscultation anterior chest of newly admitted client to med-surg. Identify type of breath sounds heard with blowing noise as air moves in and out
A. crackles (also called rales, are discontinuous sounds heard primarily during inhalation that result from air bubbling through fluid or mucus in the airways) B. rhonchi (dry, low-pitched, snoring produced in the throat or bronchial tube due to a partial obstruction from secretions) C. friction rub (a scratching or squeaking sound that persists throughout the respiratory cycle) D. normal breath sounds (normal bronchovesicular breath sounds are moderate blowing air sounds that indicate air moving through large airways during inspiration/expiration
A nurse is caring for a PT who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
A. discuss the risk factors for colon cancer B. focus teaching on what the client will need to do in the future to manage his illness C. provide client with written information about the phases of loss and grief D. reassure the client that this is an expected response to grief The client might perceive this as challenging or argumentative and react defensively. Instead, the nurse should listen to his concerns and avoid challenging him. During the anger stage of the client's psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face his future. Unless the client requests reading materials about loss, this is not an optimal time to provide them. At this stage, the client needs to express his feelings without any expectations for learning. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis.
A nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse initiate?
A. droplet B. airborne C. contact D. protective environment Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. Clients who have an immune-system compromise, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning patient care, when should the nurse initiate discharge planning?
A. during admission process (nurse must assess client's needs and plan for care during and after hospitalization) B. as soon as condition is stable (its appropriate to wait for client teaching until the client is stable and receptive to learning, but discharge planning doesnt depend on client's physiologic stability) C. during initial team conference (facilitates discharge planning but are not essential for starting the process) D. after consulting PT family (nurse must only consult with family if the client gives permission, and, in this situation, delaying discharge planning until this time could result in overlooking essential needs)
A nurse is caring for a client with Sodium 125. Which of the following findings should the nurse expect?
A. numbness of extremities (indicates hyperkalemia or potassium above 5.0) B. bradycardia (tachycardia indicates hyponatremia or sodium below 125 and hypovolemia or fluid deficit) C. positive Chvostek's sign (indicates hypomagnesemia or magesium below 1.3 and hypocalcemia or calcium below 9) D. abdominal cramping (caused by hponatremia or low sodium below 125 along with weakness, headache and nausea)
A charge nurse is observing a newly licensed nurse preparing a sterile field. Which of the following actions of the charge nurse identify as contamination of sterile field?
A. nurse opens the sterile field on a wet surface (contaminates the sterile field as capillary action can wick bacteria through the sterile drape) B. nurse opens the first fold away from his body C. nurse holds sterile objects above the waist. D. outer edge of the sterile field is touching a bottle (outer 2.5 cm or 1 inch border is not sterile)
A nurse is performing Romberg's test during a physical assessment of a PT. Which of the following techniques should the nurse use?
A. touch the face with a cotton ball B. apply a vibrating tuning fork to the clients forhead C. have the client stand iwth arsm at side and feet together D. perform direct percussion over the area of the kidneys The nurse should touch the client's corneas with a wisp of cotton and measure light touch and pain across the client's face to test cranial nerve V, the trigeminal nerve. The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to identify sound lateralization when assessing hearing. Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance. The nurse should perform direct percussion over the area of the kidneys to evaluate them for inflammation.
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions shuold the nurse take?
A. wear sterile gloves when removing the old dressing B. warm irrigation solution to 40.5° C (105° F). C. Cleanse the wound from the center outward. D. Use a 20-mL syringe to irrigate the wound. When performing wound irrigation, the nurse should - wear clean gloves to remove old dressing - warm irrigation solution to body temperature - clean the wound from the center outward to prevent introduction of microbes from outer skin surface - use a 30-60 mL syringe to irrigate the wound to create a safe but effective amount of pressure for wound irrigation
A nurse in a provider's office is obtaining health and medication history of a client with respiratory infection. The client tells the nurse that she is not aware of any allergies, but she developed a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
A."Rashes are very common, especially if you have dry skin. Did it go away on its own?" (minimizes possible adverse effect and ignores a possible need for intervention) B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic." (nurse has not gathered enoguh assessment data to draw this conclusion) C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash." (nurse must gather additional info rather than dismiss the client's concerns) D. "We need to document the exact medication you were taking because you might be allergic to it." (possiblity of allergic reaction must be reported to provider along with medication that caused the allergic response so that it is not prescribed as subsequent allergic reactions could be life-threatening)
A nurse is completeing an admission assessment of an older adult client. Which of the following findings is an indication of potential abuse?
Loss of skin turgor on the back of the hands (expected finding in older adults) Varicosities on the lower extremities (caused by decreased function of venous valves with aging) Thick, discolored nails with ridges (expected finding in older adults) Bruises on the arms in various stages of healing (indicates abuse in older adults along with burns, abrasions, fractures, bite marks, dried blood, and pressure ulcers)
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at IV site should the nurse identify as infiltration?
Peripheral IV Catheter Placement - select vein thats soft and bouncy upon palpation - place IV into client's non-dominant arm - select a vein thats distal in extremity - avoid site thats distal to previous venipuncture as this may cause infiltration Normal Results - small air bubbles in tubing - flow stops when client bends arm due to affecting circulation, but flow can be restored by repositioning - blood in the IV catheter and tubing may indicate that the catheter is in the lumen of the vein Abormal Results - exudate may indicate infection - warmth at site may indicate phlebitis - swelling (edema), cooling and skin blanching at site may indicate infiltration so the catheter must be removed and a new catheter and IV infusion must be started at a new site - bleeding may indicate a mechanical issue or anticoagulation
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Preparing for Trach Care - perform hand hygiene - open all sterile supplies and solutions - stabilize trache tube to prevent accidental extubation - don sterile gloves - preoxygenate client with 100% oxygen before suctioning -select a suction catheter half the size of the lumen to prevent hypoxemia and trauma to the mucosa - lubricate the end with sterile water or 0.9% sodium chloride irrigation - adjust the suction pressure to 120-150 mm Hg Tracheostomy Care - wear sterile gloves and provide surgical asepsis - allow 1-2 finger room under trach tie - soak inner cannula in normal saline or mixture of normal saline and hydrogen peroxide to loosen and clean secretions from inner cannula - if secretions are thick or crusty on inner cannula, use a sterile brush to remove - use commercially prepared trach dressing under tracheostomy - do not use cotton balls or gauze pads as this can cause the patient to aspirate on loose threads At Home Care -never remove outer cannula - use tracheostomy covers when outdoors to protect the airway from cold air, dust, and airborne particles -use medical asepsis with clean technique at home - use sodium chloride to cleanse site of irritated skin
A nurse is preparing infusion of Heparin for a hospitalized patient with deep vein thrombosis (DVT). The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
Ratio and Proportion STEP 1: unit of measurement = mL/hr STEP 2: Dose to administer = (Desired) 800 units/hr STEP 3: Dose available = Have 25,000 units STEP 4: no need to convert STEP 5: quantity of the dose available = 250 mL STEP 6: Set up an equation and solve for X. Have/Quantity = Desired/X 25,000 units/250 mL = 800 units/X mL X = 8 STEP 7: Round if necessary.
A nurse is assessing a clients readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the PT is ready to learn?
Readiness to learn - verbalize best time to learn - if client verbalizes the need for tools to learn and comprehend info, or redirects the nurse to teach someone else, or thinks its something he or she might not need to know, this shows reluctance and not ready to learn
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
Sleep promotion - progressive relaxation decreases stress and reduces muscle tension - exercise atleast 2 hours before bed - do not ingest any stimulants or caffein - do not reflect on the day's activities as this may cause stress or worry
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
When lifting heavy objects - bend at the knees - spread feet wide apart to create a broad base of support to promotes stability - use his arm and leg muscles which are stronger than back muscles - stand close to the object so its closer to center of gravity to reduce back strain from reaching
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with nasal cannula delivering oxygen. Which of the following actions should the nurse take first?
use least invasive interventions first when providing client care for SOB - first elevate HOB to Semi-or High-Fowler's position to facilitate maximal chest expansion and improve gas exchange (prevents excess pressure of abdominal organs on diaphragm). - increase humidity in the room (thins secretions) - administer a bronchodilator to open client's airway and facilitate breathing - remove pulmonary secretions
A nurse is preparing a change of shift report. Which of the following tools or documetns should the nurse use to communicate continuity of care?
- SBAR (Situation, Background, Assessment, Recommendations) used for change of shift report - critical pathway used to plan all client care - transfer report used when transferring or moving patient from one area or facility to another -MAR is medication administration record
A nurse is administering an otic medication for an older adult client. Which of the following actions should the nurst take to ensure the medication reaches the inner ear?
- patient in side-lying position with ear receiving instillation facing upward for 2-5 min - hold dropper 1 cm or 0.5 inches above ear canal - move auricle up and back to straight ear canal for adults or down and back for child under 3 - press gently on tragus to help medication enter inner ear - apply cotton ball to outermost portion of ear canal and remove it after 15 min
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a PT. Which of the following actions should the nurse take?
- shake the liquid medication to make sure its mixed -place client in High-Fowler's to reduce the risk of aspiration - do not transfer prepackaged liquid medication to medicine cup or measuring device as this increases the risk of altering premeasured dose
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
A. "Use the complete name of the medication magnesium sulfate B. "Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin." D. "Use the abbreviation SC when indicting an injection." The Institute for Safe Medication Practices recommends that nurses and providers -write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4 which means morphine sulfate - include a space between the dose and the unit of measure, such as 10 mg, to avoid confusion when documenting medication dosages. -designates "unit(s)" as the correct term for use in medication documentation. - "subcut" or "subcutaneously" as the correct terms for use in medication documentation and not SC
A nurse is admitting a client who has an abdominal wound with large amount of purulent drainage. Which of the following types of tranmission precautions should the nurse initiate?
A. protective environment B. airborne precautions C. droplet precautions D. contact precautions Clients who have an immune-system compromise require a protective environment. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.
A nurse is caring for a client who requires NG tube for stomach decompresion. Which of the following actions should the nurse take when inserting the NG tube?
Before Procedure - place client in High-Fowler's position with HOB 90º - tell client that insertion is uncomfortable and gag reflex will be activated, so if gag or choking occurs withdrawal tube slightly - establish communication such as raising finger or hand to indicate distress and need to pause - instruct client to breathe through mouth and swallow during insertion or tape sips of water to get tube pass the oropharynx - do not apply suction until the tube is in place and position is verified by abdominal x-ray (end of tube above pylorus) or gastric pH (0-4 acidic) -Bowel sounds are present and nausea is relieved Suctioning - Set at 80-100 mmHg for intermittent suctioning -Secure tube to gown to avoid irritating nose, getting caught on equipment or becoming dislodged - provide frequent oral care -measure drainage every shift to calculate fluid loss -apply water soluble lubricant to dried nares Open System Feeding - keep head of the bed elevated at least 30° -wipe the top of formula can with alcohol to remove or disinfect -make sure the enteral formula is room temperature to prevent the cramping and discomfort -rinse the feeding bag with warm water to reduce the risk of bacterial growth
A nurse is caring for a post-op client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following priority actions should the nurse take?
- assess or determine why the client refused incentive spirometer treatment - request respiratory therapist to encourage client use of incentive spirometer - administer pain medication to relieve pain or incision complications - if interventions to promote use of spirometer are unsuccessful, the nurse must document refusal of treatment
A nurse is caring for a PT who requires 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?
- collect urine that is free of feces - place any urine in container immediately and keep it on ice or in a refrigerator. - discard first voiding and save all subsequent voidings. - collection takes place over 24 hrs with no specified amoun
A nurse is caring for a celient who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?
- ensure interpreter and client speak same dialect - direct info, instructions and question to the client by speaking directly and observing client response - make effort to speak in short sentences - speak slowly and clearly - avoid the use of metaphors that may be hard to translate - do not use family members as interpreters - interpreter must be fluent in both languages and knowledgeable in medical terminology but no college degree required - interpretor should be same gender as client or preference; older adults may prefer someone close in age
Medication Administration via Enteral Feeding Tube
- flush feeding tube with 15-30 mL of sterile water before administration and between each medication. -dissolve each medication in 30 mL of warm sterile water -draw up medications separately and not mix . - if resistance is felt during administration, stop and contact the provider - flush feeding tube with 30-60 mL of sterile water after last medication Home Care -formula at room temperature as cold causing cramping - infuse feedings at slow, continuous drip over 8 hr each night as rapid installation causes diarrhea - wash feeding bag during each refill or x 4-8 hrs during the day -flush tubing with water before and after medications to prevent clogging
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
- place arm in dependent position to allow gravity to dilate the veins - insert catheter at 10°-30° angle - avoid using fragile veins in the hand as there is a loss of SQ tissue which allows veins to roll away, interferes with ADLs, and diminishes a sense of indepdence and mobility - clip excess hair from insertion site, but do not shave as this could lead to nicks or cuts in the skin and place patient at increase risk of infection
A nurse has an order to remove sutures from client. After retrieving suture removal kit and applying sterile gloves, which action should the nurse take next?
1. Clean sutures along the incision site (greatest risk to this client is injury from infection therefore, first action is to clean the incision to minimize the risk of infection) 2. Grasp at the knot of the sutures with forceps 3. Cut the sutures close to the skin on one side 4. Pull out the sutures with forceps in one piece
A nurse is preparing to tranfer a client with right-sided weakness from bed to chair.
1. ask or assess client's ability to bear weight and assist with transfer 2. position the chair on the client's stronger side and closest to the bed 3. have client sit and dangle feet at bedside to orthopnea or orthostatic hypotension when standing up (dizziness) 4. use stand & pivot technique to move client into the chair
A nurse is preparing to administer an injection of opioid medication. The nurse draws 1 mL out of the 2 mL vial medication. Which of the following actions should the nurse take?
- a second nurse must witness disposal of controlled substance or medication waste - pharmacies do not need to be notified - do not lock remaining controlled substance in cabinet or dispose of remaining controlled substance in sharps container as it violates Controlled Substances Act
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?
- describe location of food in clockwise pattern -allow client to decide the order in which they eat - use large handled utensils to provide easier grip and independence
A nurse in LTC facility is caring for aclient who dies during nurses shift. Identify sequence in which nurse should perform the following steps.
1. obtain death pronouncement from provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask family members if they wish to view the body 5. place name tag on the body before transfer
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV infusion over 7 hours. The nurse should set the infusion pump to deliver how many mL/hr?
107 mL/hr
A nurse is planning teaching for a group of adolescents who recently had surgical ostomy placement. Which of the following methods should the nurse use as a psychomotor approach to learning?
A. Role play (promotes cognitive and affective learning) B. Group discussions (assist adolescents with cognitive and affective learning) C. Question-answer meetings (promotes cognitive learning) D. Practice sessions (require psychomotor skills when learning)
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should hte nurse report to the provider"
A. BUN 15 B. Creatinine 0.8 C. Sodium 143 D. Potassium 5.4 Expected Range BUN 10-20 mg/dL Creatinine M 0.6 - 1.2 mg/dL or F 0.5-1.1 Sodium 136-145 mEq/L Potassium 3.5-5.0 mg/L potassium is above expected range and therefore client is at risk for dysrythmias - check BP in left and right arms
A nurse is planning care for a PT who had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to assistive personnel (AP)
APs are allowed to - Assist client with a partial bed bath - Measure BP after the nurse administers antihypertensive medication - Use a communication board to ask what the client wants for lunch APs are not allowed to - Test client's swallowing ability by providing thickened liquids -irrigate client's indwelling urinary catheter
A nurse is administering IV fluids to an older adult client. The nurse should perform which pirority assessment to monitor for adverse effects?
Adverse Effects of IV Fluids in Older Adults (fluid overload) - use ABC or airway, breathing, circulation method so ausculatate the lungs to see if crackles, dyspnea, or SOB are present then assess BP to evaluate hemodynamic stability, and measure urine output to monitor renal function, then measure serum electrolytes (sodium) to guide planning of interventions
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's needs? (Select all that apply)
In order to assess fall risk in an older adult PT, the nurse should assess - pupil clarity - visual fields tests - visual acuity
A nurse is completing admission assessment on a client who reports diarrhea and vomiting for the last 3 days. Which of the following findings would the nurse expect to find?
Neck vein distention Urine specific gravity 1.010 Rapid heart rate Blood pressure 144/82 mm Hg fluid volume deficit = urine specific gravity > 1.030 Tachycardia Hypotension Fluid volume excess = neck vein distention hypertension bradycardia
A nurse on med-surg is caring for client with new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints (Restraints without padding can abrade the client's skin) Evaluate client's circulation once per shift after application (nurse should evaluate client's circulation, ROM, vital signs, and status at scheduled intervals such as x 15 min after initial application) Remove restraints every 4 hr to evaluate the client's status (remove restraints at least x 2 hr to reposition client and assess need for hygiene and toileting) Secure the restraint ties to the client's bed side rails (secure restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury)
A nurse is reviewing a client's medication prescription which reads "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse question?
Prescription for Medication requires medication name, route, dose, frequency
A nurse is preparing to insert an IV catheter into client's arm before initiating fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
Thread the IV catheter so that the hub rests at the insertion site (Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter) Shave excess hair from around the insertion site (Shaving can increase the risk for microabrasions and infection.) Cleanse the site with hydrogen peroxide before IV catheter insertion (nurse should cleanse site with chlorhexidine or povidone-iodine) Palpate the site carefully just before inserting the IV catheter (nurse should not palpate the site after cleansing, because this can introduce micro-organisms and lead to infection unless using sterile technique)
A nurse is performing skin assessment of client with lesion on anterior thigh and expresing concern about skin cancer. Which of the findings should the nurse report to the provider as possible indication of skin malignancy?
Uniform pigmentation (variations of pigmentation indicate cutaneous malignancy) A regular border (blurry, noticed or ragged borders indicate cutaneous malignancy) An uneven shape (indicates malignancy when half the lesion looks different from other half) A diameter smaller than 6 mm (diameter bigger than 6 mm indicates malignancy)
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
contact (used for infections that spread via direct contact with clients or from environment including Vancomycin-resistant enterococci, herpes simplex) droplet (used for infections that spread via droplet nuclei larger than 5 microns including rubella, meningococcal pneumonia, streptococcal pharyngitis, pharyngeal diptheria in which nurse must wear mask when providing care or within 1-3 ft of PT) airborne (used for infections that spread via droplet nuclei smaller than 5 microns including varicella, tuberculosis, measles) protective environment (requirement for immunocompromised PTs such as those who had allogeneic stem cell transplant in order to prevent them from acquiring infections from others)
A nurse is caring for a client who had his diet prescription changed to a mechanical soft diet. Which of the following food items shoukld the nurse remove from a client's breakfast tray?
mechanical soft diet includes tomato juice, banana slices, pancakes, poached or scrambled eggs
A nurse is giving discharge instructions to a client who requires oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage therapy at home?
oxygen is highly combustible (flammable) - make sure electrical equipment is functioning properly, check wires and cords for frays - no open flame (smoking, oven, etc) - use cotton materials as wool and synthetics are flammable - keep oxygen tank in secure upright position at all times
