EAQ: Fundamental Skills

Which findings in the older client are associated with a urinary tract infection (UTI)? Select all that apply. 1 Fever 2 Urgency 3 Confusion 4 Incontinence 5 Slight rise in temperature

Confusion Incontinence Slight rise in temperature An older client with a urinary tract infection (UTI) is likely to appear confused. An older client may experience incontinence while a younger client may experience urgency. The older client may develop a slight rise in temperature. The classic symptoms of a UTI in a younger client are fever, dysuria, and urgency.

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? 1 Soap 2 Time 3 Water 4 Friction

Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 am the healthcare provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the 8-hour shift? Record your answer using a whole number. ___ mL

The client will have absorbed 313 mL of solution before the healthcare provider changes the prescription (2.5 hours × 125 mL/hour = 312.5, rounded up to 313); for the remaining 5.5 hours of the shift, the client will have received 550 mL (5.5 hours × 100 mL/hour), for a total of 863 mL.

What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? 1 Knowledge reduces general anxiety. 2 Capacity to learn decreases with age. 3 Continued reinforcement is advantageous. 4 Readiness of the learner precedes instruction.

Continued reinforcement is advantageous. Neurologic aging causes forgetfulness and a slower response time; repetition increases learning. That knowledge reduces general anxiety, that the capacity to learn decreases with age, and that the readiness of the learner precedes instruction reflect principles applicable to all learning regardless of the client's age. Learning occurs, but it may take longer.

A nurse in the emergency department is assessing a young child with a head injury. The child is accompanied by a parent. Which observation should prompt the nurse to assess the child for abuse? 1 The child has Mongolian spots on the back. 2 The child belongs to a single-parent family. 3 The child has received care for injuries twice earlier. 4 The child and parent narrate the same story about the injury.

The child has received care for injuries twice earlier. The nurse should assess the child for abuse if the child has received care for injuries on two earlier occasions. Frequent emergency visits for injuries should prompt the nurse to further investigate the case. Mongolian spots are normal variants of skin coloration obtained at birth and do not need further evaluation. A single-parent home does not indicate that the child is a victim of abuse. The nurse need not assess the child for abuse if both the parent and the child narrate the same story.

Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 Facilitating a program about smoking cessation

Assisting with immunization programs Facilitating a program about smoking cessation Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1 Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2 After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3 Clean the insertion site daily using a solution of one part vinegar to two parts water. 4 Replace the drainage bag with a new bag once a week.

Replace the drainage bag with a new bag once a week. It is recommended to change the bag at least once a week. Once a day, the client should wash the first inches of the catheter, starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution.

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain what? 1 Abduction 2 Adduction 3 Traction 4 Elevation

Abduction Abduction means to move the limb away from the median plane, or axis, of the body. In care of the client with a fractured hip, the legs and hip must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. In a client with a fractured hip, adduction of the limb, traction, and elevation are not appropriate procedures. Adduction means to move the limbs toward the medial plane, or axis, of the body, and traction involves the process of applying a pulling force in opposite directions using weights.

When permitted by the client, the nurse should always take the time to keep the family informed about what is happening to the client. The purpose of this approach is that informed families will be what? 1 Able to decrease the client's anxiety 2 More relaxed when interacting with the client 3 Less likely to cause problems with the nursing staff 4 Better equipped to undertake necessary family role changes

Better equipped to undertake necessary family role changes Early notification provides an opportunity to prepare for change. The ability to decrease the client's anxiety, families being more relaxed, and families being less likely to cause problems with nursing staff may be secondary gains, but are not the primary purpose.

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? Select all that apply. 1 Gloves 2 Gown 3 Mask 4 Goggles 5 Shoe covers 6 Hair bonnet

Gloves Gown Goggles Standard PPE, which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. Shoe covers and hair bonnet are not required for the patient care situation described.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1 Evaluation 2 Assessment 3 Nursing interventions 4 Proposed nursing care

Assessment An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.

Only a small part of the body is irradiated. Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the healthcare provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1 "Inhale completely and exhale in short, rapid breaths." 2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3 "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4 "Exhale halfway, then inhale a rapid, small breath; repeat several times."

"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. When teaching clients, it is important to provide exact step-by-step instructions, thus not leaving out any critical points.

When trying to promote effective learning in a client with a newly diagnosed disease, what should the nurse consider? 1 Client's past experiences 2 Client's personal resources 3 Stress of the total situation 4 Type of onset of the disease

Client's past experiences Past experiences have the most meaningful influence on present learning. Although the client's personal resources, the stress of the total situation, and the type of onset of the disease affect learning, their influence is not as great as past experiences.

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism

Detachment When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic, but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

A client who underwent thyroid surgery is unable to speak and communicate. The nurse initially uses closed-ended questions to assess the client's needs. Once the client is stable, the nurse provides a small white board for the client to write and communicate to others. Which critical thinking attitude has the nurse demonstrated? 1 Humility 2 Discipline 3 Risk taking 4 Perseverance

Perseverance Perseverance is finding effective solutions to problems by trying various approaches. A critical thinker would demonstrate perseverance by not becoming satisfied with the solution unless the solution is near perfect. Humility is accepting one's limitations. Discipline is effective management of time and resources. Risk taking is pushing oneself beyond the limits to find solutions to the problem.

A nurse is reviewing a client's serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid? 1 They both contain the same kinds of ions. 2 Plasma exerts lower osmotic pressure than does interstitial fluid. 3 Plasma contains more of each kind of ion than does interstitial fluid. 4 Sodium is higher in plasma, whereas potassium is higher in interstitial fluid

They both contain the same kinds of ions. Blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition. The osmotic pressure is the same. The composition is the same. The main cation of both extracellular fluids is sodium.

A registered nurse is teaching a nursing student about caring for a client before leaving the healthcare facility. Which statement made by the nursing student indicates the need for further education? 1 "I should teach the client about potential food-drug interactions." 2 "I should involve the client and his or her family in the referral process." 3 "I should give limited information about the client to the healthcare provider who received the referral." 4 "I should teach the client and his or her family about safe and effective use of medications and medical equipment."

"I should give limited information about the client to the healthcare provider who received the referral." The nurse should provide as much client information as possible to the healthcare provider who received the referral because this action helps to avoid the provider asking duplicate questions and helps to avoid the omission of important information. The nurse should instruct the client about any potential food-drug interactions. The nurse should involve the client and his or her family in the referral process. The nurse should teach the client about the safe and effective use of medications and medical equipment.

The nurse manager asks the nurse, "How would you implement clinical decision making in a group of clients?" Which answer provided by the nurse shows effective critical thinking? Select all that apply. 1 "I will avoid involving clients as decision-makers and participants in care." 2 "I will discuss complex cases with other members of the healthcare team." 3 "I will identify the nursing diagnoses and collaborative problems of each client." 4 "I will consider the period it takes to care for clients whose problems have higher priority." 5 "I will decide to perform activities individually to resolve more than one client problem at a time."

"I will discuss complex cases with other members of the healthcare team." "I will identify the nursing diagnoses and collaborative problems of each client." "I will consider the period it takes to care for clients whose problems have higher priority." The nurse should discuss complex cases with the other members of the healthcare team. It ensures a smooth transition in the care requirements. As a part of effective critical thinking, the nurse should diagnose the collaborative problems of each client. The nurse should consider the care time for the clients having problems that require high priority. Effective critical thinking requires the nurse to involve clients as decision makers or participants in care. The nurse should decide on combining activities to resolve more than one client problem at a time.

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). 4 Clamp the tube for 2 minutes and then restart the infusion.

Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill? 1 Knowledge of the grieving process 2 Personal feelings about terminal illness 3 Recognition of the family's ability to cope 4 Previous experience with terminally ill clients

Personal feelings about terminal illness To be effective in a relationship with a client, the nurse must know and understand personal feelings about terminal illness and death. Knowledge alone is not enough to ensure an effective nurse-client relationship. Although the family is an important part of a client's support system, the client's feelings are more important to the relationship. Previous experiences can be positive or negative and will not guarantee an effective nurse-client relationship.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery

Prayer Hypnosis Aromatherapy Guided imagery Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? 1 Social 2 Physical 3 Materialistic 4 Environmental

Social Without some form of communication, there can be no socialization. People interact with other social beings, not with inanimate objects. Physical, materialistic, and environmental surroundings are all inanimate and cannot interact.

Which intervention by the nurse helps the family feel in control when the client is to be discharged home? 1 Instruct the family to ensure the client's room is safe. 2 Ask the family to ensure that the client has only low-fat meals. 3 Ask the family to coordinate with the staff at the rehabilitation center. 4 Ensure a family member is confident about changing dressings correctly.

Ensure a family member is confident about changing dressings correctly. The nurse should identify a family member who is capable and willing to learn how to change the client's dressings. The nurse should teach a family member and have that member demonstrate the process to ensure the procedure is executed correctly. This gives confidence to the client and family, who will feel in control when the client is discharged home. The nurse should not only instruct but also offer suggestions about rearranging the client's room to make it safe. The nurse should offer suggestions and ask the family for ideas on how to prepare low-fat meals that meet their ethnic considerations. The nurse should coordinate with the nursing staff at the rehabilitation center to ensure continuity of care.

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. What should the nurse be aware of when using the problem-etiology-signs and symptoms (PES) format? 1 Signs and symptoms come last in the diagnostic process. 2 Nursing interventions are derived from the etiology statement. 3 The only allowable diagnoses are nursing diagnoses. 4 Nursing diagnoses deal only with actual or potential illness problems.

Nursing interventions are derived from the etiology The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the signs and symptoms, or "S" in the acronym, comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses handle most commonly with other healthcare providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1 Orient the client to the unit environment. 2 Have a copy of hospital regulations available. 3 Explain that there is no reason to be concerned. 4 Reassure the client that the staff is available if the client has questions.

Orient the client to the unit environment. Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. Explaining that there is no reason to be concerned may be false reassurance because no one can guarantee that there is no reason to be concerned. Reassuring the client that the staff is available to answer questions implies that staff members are available only if the client has specific questions.

A primary nurse completes a nursing assessment of all assigned clients and develops a care plan for each client. Which element of decision-making does the nurse execute in this situation? 1 Authority 2 Autonomy 3 Responsibility 4 Accountability

Responsibility Responsibility refers to duties and activities that an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given issue. Autonomy refers to freedom of choices and the responsibility for the choices. Accountability refers to individuals being answerable for their actions.

Which warning signals should the nurse observe in a child suspected to be a victim of abuse? Select all that apply. 1 The child doesn't want to be touched by anyone. 2 The child sleeps for an average of 15 hours a day. 3 The child frequently visits the emergency department. 4 The child suffers from fever and tenderness in the abdomen. 5 The child looks at the caregiver before answering any question.

The child doesn't want to be touched by anyone. The child frequently visits the emergency department. The child looks at the caregiver before answering any question. The child may become scared if touched. The physical abuse may cause injuries and the child may visit the emergency department frequently. An abused child may look at the caregiver before answering any question due to fear. The child sleeping for an average of 15 hours a day does not indicate abuse. Fever and tenderness in the abdomen are not signs of abuse; it could indicate an organic cause.

Which situation is an example of a protective touch that may elicit negative feelings in a client? 1 The nurse provides a back massage to a client. 2 The nurse obtains a blood sample for laboratory tests. 3 The nurse holds a client while assisting with ambulation. 4 The nurse withdraws from a client to escape the situation.

The nurse withdraws from a client to escape the situation. The nurse may use protective touch and withdraw from the client to escape a tension-filled situation. This type of protective touch may protect the nurse emotionally but elicit negative feelings in a client. The nurse enhances the self-esteem and improves the mental well-being of a client by providing a back massage. This intervention is called a caring touch or nonverbal communication. The nurse performs task-oriented touching while obtaining a blood sample for laboratory tests. The nurse provides a protective touch that protects the client while assisting with ambulation.

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? 1 Dialysis 2 Osmosis 3 Diffusion 4 Capillarity

Capillarity When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low concentration.

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? 1 Airway obstruction 2 Inadequate nutrition 3 Prolonged gastric suction 4 Excessive mechanical ventilation

Excessive mechanical ventilation The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

Arrange the steps involved in applying a surgical mask. Incorrect Hold the mask by its two strings or loops Secure two top ties at the back of head, with ties above the ears Tie two lower ties snugly around the neck with the mask well around the chin Find the top edge of mask Gently pinch the upper metal band around the bridge of the nose

Find the top edge of mask Hold the mask by its two strings or loops Secure two top ties at the back of head, with ties above the ears Tie two lower ties snugly around the neck with the mask well around the chin Gently pinch the upper metal band around the bridge of the nose If a mask is properly applied, it fits the mouth and nose securely so that pathogens and body fluids cannot enter or escape through the sides. First, the mask's top edge should be identified and the mask should be held by its two strings. Then, the two top ties are tied at the back of the head, with the ties above the ears. The lower two ties are tied around the neck with the mask well around the chin. Then, the upper metal band should be pinched around the bridge of the nose.

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." What does the nurse determine that the client needs to be taught about? 1 Need for home-delivered meals 2 Foods that meet basic nutritional needs 3 Effect of aging on the need for some foods 4 Need for meat at least once per day throughout life

Foods that meet basic nutritional needs The need for nutrients, including protein, that meet basic nutritional needs continues throughout life. The priority is to educate the client, although home-delivered meals may be one way to provide adequate nutrition. Aging has no effect on the specific nutrients needed; however, it may influence digestion or absorption of food. Protein is needed every day, but it does not have to be in the form of meat.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the primary healthcare provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought.

Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a healthcare proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the primary healthcare provider for an administrative prescription are without legal basis, and the nurse may be held liable.

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The healthcare provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis

Surgical asepsis Catheter insertion requires the procedure to be performed under sterile technique. Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in response to this client's question? Select all that apply. 1 "Ask your healthcare provider how and when you should be taking your medications." 2 "Stop taking a prescribed medication if you are not feeling better in a few days." 3 "Discard medications into the toilet that have exceeded the expiration date on the bottle." 4 "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." 5 "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."

"Ask your healthcare provider how and when you should be taking your medications." "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest." If unsure about any information, the client should be encouraged to ask for further instructions and more information. A client needs to be proactive and should check all aspects of the prescription with the pharmacist before leaving the pharmacy. A pharmacist may have permission to substitute a generic form of the drug or may change the number of pills that deliver the prescribed dose, both of which can confuse the client (e.g., one tablet may deliver 50 milligrams of a drug and be equal to two 25-milligram tablets). Because of the risk of drug interactions associated with polypharmacy and altered age-related physiological functioning that can cause drug toxicity, the client should inform the health team about all drugs (e.g., prescription, over-the-counter, recreational), herbal preparations, and amount of alcohol ingested to ensure safety. A client should stop taking a prescribed medication only after consultation with the health care provider. Unused and expired medications should not be discarded into the toilet because they can contaminate groundwater.

The nurse is questioning a client who reports pain. Which questions asked by the nurse are appropriate? Select all that apply. 1 "Where does it hurt?" 2 "What makes the pain worse?" 3 "How long have you noticed it?" 4 "Have you been treated for pain previously?" 5 "How severe is your pain on a scale of 0 to 10?"

"Where does it hurt?" "What makes the pain worse?" "How long have you noticed it?" "How severe is your pain on a scale of 0 to 10?" The nurse should follow an orderly and systematic approach when collecting information. The nurse should ask specific questions of the client such as "Where does it hurt?", "What makes the pain worse?", "How long you have noticed it?" and "How severe is your pain on a scale of 0 to 10?" Questions such as "Have you been treated for pain previously?" should be asked after understanding the characteristics of the pain.

The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number. ___mL

1 ounce = 30 mL; therefore the client ingested 120 mL of orange juice at 8:30 am, 180 mL of tea at 8:30 am, 60 mL of water with medications at 10:00 am, 90 mL of soup at 12:30 am, and 120 mL of ice cream at 12:30 pm (counted as a liquid because it melts at room temperature). The client received 400 mL of IV fluid (50 mL × 8 hours = 400). Total intake is 970 mL. Vomit and urine output should not be included in the patient's intake.

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? 1 Accept the client's behavior. 2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions.

Accept the client's behavior. At this time the client is using this behavior as a defense mechanism. Acceptance can be an effective interpersonal technique because it is nonjudgmental. Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies nonacceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions. Apply clean gloves within the gown Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist Bring the glove cuffs over the edge of the gown sleeves Apply eyewear or goggles snugly around the face and eyes Apply either a surgical mask or a respirator around the mouth and nose

Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist Apply either a surgical mask or a respirator around the mouth and nose Apply eyewear or goggles snugly around the face and eyes Apply clean gloves within the gown Bring the glove cuffs over the edge of the gown sleeves When preparing to enter an isolation room, the nurse first needs to apply a cover gown pull the sleeves down to wrist, and tie securely at neck and waist. The nurse should wear either a surgical mask or a respirator around his or her mouth and nose. If necessary, apply eyewear or goggles snugly around the face and eyes. Next, the nurse should wear gloves within the gown and pull the glove cuffs over the gown sleeves.

Arrange the events of communication throughout the nursing process in chronological order. Performing verbal, visual, auditory, and tactile health teaching activities Documenting expected outcomes Identifying the factors affecting the outcomes Assessing the medical records and diagnostic tests Intrapersonal analysis of the assessment findings

Assessing the medical records and diagnostic tests Intrapersonal analysis of the assessment findings Documenting expected outcomes Performing verbal, visual, auditory, and tactile health teaching activities Identifying the factors affecting the outcomes The first step of communication throughout the nursing process is assessment, which involves assessing medical records and diagnostic tests. The second step is nursing diagnosis, which involves the intrapersonal analysis of assessment findings. The third step is planning, which involves the documentation of expected outcomes. The fourth step is implementation, which involves performing verbal, visual, auditory, and tactile health teaching activities. The final step is evaluation, which involves identifying the factors affecting the outcomes.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer.

Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen. Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the onset of the Alzheimer dementia, and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1 Exploring the client's emotional conflict 2 Identifying personal feelings toward this client 3 Planning to discuss this with the client's family 4 Developing a rapport with the client's healthcare provider

Identifying personal feelings toward this client Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

In what position should the nurse place a client recovering from general anesthesia? 1 Supine 2 Side-lying 3 High Fowler 4 Trendelenburg Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client, because it interferes with breathing.

Side-lying Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client, because it interferes with breathing.

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 1 Weak upper arm strength and impaired stamina 2 Weight bearing as tolerated and unilateral paralysis 3 Partial weight bearing on the affected extremity and kyphosis 4 Strong upper arm strength and non-weight bearing on the affected extremity

Strong upper arm strength and non-weight bearing on the affected extremity A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? Select all that apply. 1 Taking on parental roles 2 Adjusting to a reduction in family size 3 Development of intimate peer relationships 4 Adjusting the marital system to make space for children 5 Realigning relationships to in-laws and grandchildren

Taking on parental roles Adjusting the marital system to make space for children A family with more young children undergoes an emotional transition of accepting a new generation of members. These changes include taking on parental roles and adjusting the marital system to make space for children to proceed developmentally. Adjusting to a reduction in family size is required for the family life-cycle stage of children leaving the family home. The development of intimate peer relationships is required for an unattached young adult. Realigning relationships to in-laws and grandchildren is required for the family life-cycle stage of children leaving the home to start their own lives.

The nurse assessing an adult understands that the client is experiencing a midlife crisis. Which factor should the nurse attribute to this condition? 1 The client is seeking an occupational direction. 2 The client is examining life goals and relationships. 3 The client is directing energy towards achievements. 4 The client is sharing responsibilities in a two-career family.

The client is examining life goals and relationships. Individuals between the age of 35 and 43 are vigorously examining their life goals and relationships. These individuals often experience stress or a midlife crisis during this reexamination, which may lead to changes in personal, social, and occupational areas. A young adult who is aware of his or her skills seeks to pursue a degree suitable to his or her desired occupation. A young adult between the ages of 29 to 34 directs enormous energy toward achievement and mastery of the surrounding world. A young adult must share all responsibilities in a two-career family to avoid stress.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. 1 The nurse keeps the newborn covered in warm blankets. 2 The nurse keeps the newborn under the radiant warmer. 3 The nurse places the newborn on the mother's abdomen. 4 The nurse measures the newborn's temperature regularly. 5 The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

The nurse keeps the newborn covered in warm blankets. The nurse keeps the newborn under the radiant warmer. The nurse places the newborn on the mother's abdomen. Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.