Exam 1 Review 3C's Quiz
A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist." "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine." "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower." "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed."
"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist." Explanation: The best way to explain caregiving is to describe the specific position and type of chair to use as well as teach the caregiver why it is the best position and device. Teaching the caregiver to place the parent at the sink and then stand outside the shower does not provide the best position nor the device to obtain, plus it does not address the facts that the parent standing in the shower may not be possible due to hypoxia and is not safe. Teaching the caregiver to use whichever position is most comfortable for the parent does not address the safest position for the client nor the position that provides easiest breathing and energy conservation. Standing for the period of time it may take to complete daily hygiene is not feasible or safe for the client and should not be recommended by the nurse.
The nurse is instructing a client with xerostomia (dry mouth) about taking several pills and capsules that have been prescribed. What statement made by the client indicates to the nurse that the client understood the instructions? "If I cannot swallow the pills, I will hold the dose and take both doses later in the day." "I will take a sip or two of water prior to taking my pills." "The best time to take my medications is first thing in the morning before eating." "I will have to get a speech therapy appointment before taking the pills."
"I will take a sip or two of water prior to taking my pills." Explanation: The nurse knows the client has understood the instructions when the client mentions drinking water prior to taking medications. Xerostomia, or dry mouth, may be present in some older adult clients who have diminished salivary gland secretions, which makes taking medication difficult without moisture. The client should not double up on any medication without the advice of the health care provider. Taking the medication in the morning may be difficult due to the dryness. Speech therapy consultation is beneficial when the client has dysphagia, especially after experiencing a stroke, but there is no evidence in this scenario to indicate this client has dysphagia.
The nurse is teaching a client about venlafaxine XR. When the client asks, "What does the XR mean?" what is the appropriate nursing response? "It means sustained release." "It means extended release." "It means sustained action." "It means continuous release."
"It means extended release." Explanation: The nurse will clarify that XR means extended release. SR means sustained release; CR means continuous release; and SA means sustained action.
Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply. "Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation." "Most pressure injuries occur over the trochanter and calcaneus." "The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." "Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue."
"The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation." "Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." Explanation: Pressure injuries usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation. Pressure injuries can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure injury can appear in less than 2 hours of time, depending on the factors present. Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.
The client is being discharged, and the nurse is reviewing the newly prescribed medications with the client. Which statement(s) will allow the nurse to evaluate the client's understanding of the medications? Select all that apply. "If you have questions, ask the pharmacist at the pharmacy where you obtain your medications." "What is the reason you are taking each medication?" "I will provide you with written information about each medication before you leave." "Tell me what time of day you are to take your medications." "Do you have any questions about your medications?"
"What is the reason you are taking each medication?" "Tell me what time of day you are to take your medications." Explanation: In evaluating the client's understanding of the medication, the nurse will have the client explain the purpose and times for administration of each medication. Asking if the client has questions may elicit a "no" response even if the client has questions. Telling the client to ask the pharmacist does not evaluate understanding about the medications. Providing information about the medications is part of the education process. It does not evaluate the client's understanding.
A nurse is administering intramuscular injections to clients. What needle size(s) has the nurse used correctly? Select all that apply. 5/8-inch (2-cm) needle for the vastus lateralis site 1 1/2-inch (3.75-cm) needle for an adult in the deltoid site 5/8-inch (2-cm) needle for an adult in the ventrogluteal site 1 1/2-inch (3.75-cm) needle for a child in the deltoid site 5/8-inch (2-cm) needle for an adult in the ventrogluteal site 5/8-inch (2-cm) needle for a child in the deltoid site
5/8-inch (2-cm) needle for the vastus lateralis site 1 1/2-inch (3.75-cm) needle for an adult in the deltoid site 5/8-inch (2-cm) needle for a child in the deltoid site Explanation: The acceptable size for needles based on the muscle being used for the injection is:Vastus lateralis 5/8-inch to 1-inch (2 to 2.5 cm)Deltoid (children) 5/8-inch to 1-inch (2 to 2.5 cm)Deltoid (adults) 5/8-inch to 1 1/2-inch (2 to 3.75 cm)Ventrogluteal (adults) 1 1/2-inch (3.75 cm)
A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. Analyzing data Identifying patterns Collecting subjective and objective data Organizing data Identifying indicators of potential dysfunction
Analyzing data Identifying patterns Identifying indicators of potential dysfunction Explanation: During the diagnosis phase, the nurse analyzes collected data; identifies client strengths; identifies the client's normal functional level and indicators of actual or potential dysfunction; identifies patterns; validates the diagnosis; and formulates a diagnostic statement in relation to this synthesis. Collecting and organizing data are assessment activities.
Which guidelines should the nurse consider when writing outcomes? Select all that apply. The nurse should derive each set of outcomes from a combination of nursing diagnoses. The nurse should not be concerned if the client and family do not value the outcomes as long as they support the plan of care. At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse may write outcomes that do not specify a timeline as long as they are linked with other outcomes. The outcomes the nurse writes need not be supportive of the total treatment plan as long as they specify a goal. The nurse should write outcomes that are brief and specific and support the overall plan of care.
At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should write outcomes that are brief and specific and support the overall plan of care. Explanation: Resolution of the client problem should be a priority; therefore, at least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. Outcomes that are brief and specific are more readily evaluated. The nurse should derive each set of outcomes from a single nursing diagnosis, rather than a combination. The client and family must value the outcomes to work toward the goal. The outcomes must support the overall treatment plan; simply including a goal is not enough. Timelines for outcomes are necessary so that they can be measured and evaluated.
After performing an assessment on a client, the nurse determines that the client is having difficulty with airway clearance. The nurse supports this suspicion by listing as evidence: a nonproductive cough, crackles in the lower lobes, and a pulse oximeter reading of 94%. The nurse used which process? Verifying Inferring Clarifying Clustering
Clustering Explanation: Clustering related data helps the nurse look for and test impressions about patterns of human functioning. Putting like data together—for instance, objective data related to the respiratory system, such as cough, crackles, respiratory rate, and pulse oximetry—can better help the nurse identify problems and trends. To verify is to make sure or demonstrate that something is true, accurate, or justified. To infer is to deduce or conclude information from evidence and reasoning rather than from explicit statements. To clarify is to make a statement or situation less confusing and more clearly comprehensible.
The nurse is reading a medication prescription for a drug that is routinely administered every 12 hours. The prescription does not state the frequency of administration. What is the appropriate nursing action and accompanying rationale that guides the nurse's action? Contact the health care provider to clarify the prescription. Assumptions cannot be made about medication administration and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration. Ask the client how often this drug is taken at home, because this is not an assumption and is within the state's nurse practice act and the organization's policies and procedures concerning medication administration. Review medication literature and request that another nurse validate the frequency as every 12 hours. As long as two nurses verify the missing information contacting the health care provider is not necessary. Input the prescription into the electronic health record (EHR) to show that the drug is given every 12 hours because EHRs are able to detect an incorrect frequency and will warn the nurse if it is an error.
Contact the health care provider to clarify the prescription. Assumptions cannot be made about medication administration and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration. Explanation: The nurse should always have the health care provider clarify the prescription. The nurse cannot assume that a medication is to be given at certain times, nor should the client (or another nurse) clarify this. Reviewing medication literature may assist the nurse in understanding more about the medication, however, deciding the frequency of a dose falls under prescribing medication and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration. Electronic health records are not fail proof and the nurse should not add the missing information without provider clarification.
A nurse educator is reviewing information related to medication administration documentation with a group of graduate nurses. Which guideline for documenting will the nurse discuss with the group? Document administration of the medication immediately after administering the drug. Document administration of the medication after the nurse has determined it caused no side effects. Document administration of the medication immediately prior to giving the drug. Document administration of the medication at the end of the nursing shift.
Document administration of the medication immediately after administering the drug. Explanation: Record each dose of medication as soon as possible after it is given and do not record medications before they are given. Documenting immediately after administering a drug provides a documented record that can be consulted if there are any questions about whether the client received the medication. Nurses need to be vigilant of side effects that may occur with either first time or repeated doses of medications. There can be delayed side effects and the nurse should document as soon as possible so the nurse and others can determine if the side effect was from a particular medication.
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? It can cause the nasal mucosa to dry in case of high flow. It can result in an inconsistent amount of oxygen. It can cause anxiety in clients who are claustrophobic. It can create a risk of suffocation.
It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.
The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. Use a dry sterile applicator at a 90-degree angle to measure depth. Draw the shape of the wound with a description. Chart tunneling by using a quadrant approach to describe the location.
Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. Draw the shape of the wound with a description. Explanation: When charting the findings, draw an irregular-shaped wound, as in this question, and provide a description including its length and width. A sterile applicator moistened with saline should be used to measure the depth of a wound and to determine the presence of tunneling. A dry applicator could damage the wound by sticking to it. The nurse would use the imaginary face of a clock when describing where on the wound the locations of tunneling exist. The nurse would assess the color of the wound, and presence of drainage, pain or discomfort, and any complications, and include these in the charting.
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? SpO2 96% heart rate 110 beats/minute respirations 26 breaths/minute clubbing of fingers
SpO2 96% Explanation: An SpO2 at or above between 95% and 100% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/min, and a heart rate greater than 100 beats/min may indicate that more oxygen is needed.
The health care provider writes a prescription for ampicillin 1 gram every 6 hours for a client. What would cause the nurse to question this medication prescription? The route is missing. The amount is missing. The time is missing. The frequency is missing.
The route is missing. Explanation: The rights of medication administration include client, drug, route, dose, time, reason, and documentation. This medication prescription does not identify a route. Ampicillin can be administered intravenously, intramuscularly, or orally.
Which nursing actions help improve listening skills when conversing with clients? Select all that apply. Sitting with the arms crossed Always maintaining eye contact with the client in a face-to-face pose Thinking before responding to the client, even if this creates a lull in the conversation Using facial expressions and body gestures to indicate attention to what the client is saying Listening for themes in the client's comments Pretending to listen to the client while performing a task rather than interrupting the client's conversation
Thinking before responding to the client, even if this creates a lull in the conversation Using facial expressions and body gestures to indicate attention to what the client is saying Listening for themes in the client's comments Explanation: The following nursing actions would help improve listening skills when conversing with clients: using facial expressions and body gestures to indicate attention to what the client is saying; thinking before responding to the client, even if this creates a lull in the conversation; and listening for themes in the client's comments. The nurse should not cross the arms or legs while communicating with a client because this body language conveys a message of being closed to the client's comments. A face-to-face pose and maintaining eye contact would not be appropriate in all nurse-client relationships. The nurse would not pretend to listen to the client while performing a task rather than interrupting the client's conversation.
The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. To monitor clients' responses to treatment To help establish a diagnosis To reveal changes from previously collected data To help clients feel that something is being done for them To confirm previously collected data
To monitor clients' responses to treatment To help establish a diagnosis To reveal changes from previously collected data To confirm previously collected data Explanation: Reports of laboratory data are used to either confirm or reveal changes from data previously collected. The diagnostic studies also help health care providers establish a diagnosis and monitor the client's response to treatment. The labs are not used to make the client feel better.
While planning care for a client immediately after surgery, the nurse formulates a nursing diagnosis of "Risk for Injury." Which assessment data would be appropriate for the nurse to identify as possible etiologies for the diagnosis? Select all that apply. Unfamiliarity with the hospital environment Effects of pain medications Visual deficit Impaired mobility Two side rails up at all times
Unfamiliarity with the hospital environment Effects of pain medications Visual deficit Impaired mobility Explanation: Potential hazards that would indicate a "Risk for Injury" include anything that hinders the client's ability to self-protect. Visual deficits, the disorienting effects of pain medications, deficits in mobility, and being unfamiliar with the environment all increase the safety hazards of the client. Two side rails up at all times is a possible nursing intervention used to help protect the client.
The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented? Have the unlicensed assistive personnel (UAP) to monitor the client until medication is taken. Ask the client's family to confirm that the client has swallowed the medication. Allow the client to sign for the medication and keep the medications on a bedside table until ready to take them. Wait with the client until the medications are taken.
Wait with the client until the medications are taken. Explanation: The nurse must wait with the client to personally acknowledge that medications have been taken (or refused). This action ensures that the medication was administered to the right client, right route, and at the right time. It is not appropriate to leave medications with a client, to ask family to confirm administration, or to leave the room without knowing that the client has taken (or refused) the medications. Therefore, leaving the UAP to monitor medication administration is not safe practice.
The nurse is providing care to an older adult client. Which intervention(s) will the nurse perform to protect the client's skin? Select all that apply. apply moisturizing lotion to feet and hands daily wash the perineal area every day provide a bed bath every day minimize the use of any tape on the skin offer fluids every hour while the client is awake
apply moisturizing lotion to feet and hands daily wash the perineal area every day minimize the use of any tape on the skin offer fluids every hour while the client is awake Explanation: Nursing interventions to protect the older adult client's skin include applying moisturizing lotions to feet and hands. This is because the older client's skin becomes more dry as the person ages. The nurse protects the skin from injury by minimizing the use of tape on the skin. The older adult client's skin is more easily injured. The nurse washes the perineal area daily and as needed to clean the skin of urine and feces. Both are irritants to the skin and may cause damage. The nurse offers fluids to the client to ensure adequate hydration, which helps protect the skin. The nurse does not bathe the older client every day, since this will cause the skin to become more dry.
At what point should the nurse perform the first of the three checks of medication administration? when reviewing the client's medication administration record (MAR) as the nurse reaches for the drug package or container at the beginning of a shift after retrieving the drug from the drawer of a drug cart
as the nurse reaches for the drug package or container Explanation: The first of the three checks associated with safe medication administration takes place when the nurse reaches for the container or unit dose package. The three checks are: 1. when the nurse reaches for the unit dose package or container; 2. after retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container; 3. before giving the unit dose medication to the client, or when replacing the multidose container in the drawer or shelf. At the beginning of a shift is too early to complete the first of three safe medication checks. A nurse reviews the client's medication administration record (MAR) as a part of the morning assessment to identify when medications are due. This is part of the second check of frequency with the MAR. After retrieving the drug from the drawer of a drug cart is part of the third check of frequency.
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? alterations in the structures of the ribs and diaphragm lower-than-normal concentrations of environmental oxygen rapid decreases in atmospheric and intrapulmonic pressures changes in the alveolar-capillary membrane and diffusion
changes in the alveolar-capillary membrane and diffusion Explanation: Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult. Diffusion is assessed by a decreased oxygen saturation measurement. The environmental oxygen which comprises the atmospheric pressure, ribs, and diaphragm do not influence the diffusion of gas exchange inside the lungs.
What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply. pressure redistribution support surfaces head of bed positioned at 45 degrees proper client nutrition client repositioning with a lift 2-hour turn schedule pillow placed under knees
pressure redistribution support surfaces proper client nutrition 2-hour turn schedule client repositioning with a lift Explanation: To protect clients at risk for the adverse effects of pressure, the nurse will implement turning on an every-2-hours schedule in the health care setting. More frequent position changes may be necessary, depending on the client. Use of a pressure redistribution support surface can be expensive, but it is an effective way to prevent a pressure injury. The nurse will also keep heels from pressing on the bed for immobile clients and advise against prolonged sitting. While sitting or lying, the client will use positioning devices or pillows to keep boney prominences from rubbing on each other or pressing onto a surface. Placing pillows under the knees while supine puts pressure on the heels against the mattress. The nurse will protect the client's skin from friction and shear by lifting the client when moving or repositioning and keep the head of bed at 30 degrees or less. Positioning at client on a bed while the head of the bed is at a 45 degree angle could cause the client to have a skin shear or friction injury. The nurse will provide adequate calories and nutrients.
The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply. the client who is experiencing an allergic reaction and is scratching the skin the client who is emaciated from self-induced vomiting and food deprivation the ambulatory client who is recovering from an endoscopic procedure for abdominal pain the client who has a temperature of 104°F (40°C) and is perspiring the client who has a body mass index (BMI) of 34
the client who is experiencing an allergic reaction and is scratching the skin the client who is emaciated from self-induced vomiting and food deprivation the client who has a temperature of 104°F (40°C) and is perspiring the client who has a body mass index (BMI) of 34 Explanation: The clients at risk for injury to the skin are the client with a BMI of 34, the emaciated client, the perspiring client, and the client who is scratching. The client with a BMI of 34 is obese, placing him at risk for skin irritation and injury. The emaciated client is also at risk for skin irritation and injury due to poor nutrition. The perspiring client has excessive moisture that predisposes the client to skin breakdown, particularly in skin folds. The client who is scratching may tear the skin. The ambulatory client will be mobile within a few hours of the endoscopic procedure.