Exam #3 - Fundamentals - 4/10/20

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

"Always test the temperature of bath water before stepping in."

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?

"Antibiotics have no effect on viruses."

A client has been diagnosed with diabetes and requests information about complementary therapies that could do along with the prescribed treatment plan. What would be the nurse's best response to this client?

"Healing is slow in complementary therapy, it involves the whole person, and care is individualized. "

A nurse is conducting a health history and asks the client about use of complementary and alternative medicine (CAM) to treat her chronic headaches. Which response would require further questions?

"I take herbs to treat my headaches."

In order to prevent the possibility of venous stasis, a nurse is educating a surgical client on how to perform leg exercises. Which statement by the client indicates a sound understanding of leg exercises?

"I'll practice these now and try to start them as soon as I can after my surgery."

A nurse is attending a job fair at the local community center and stops at a booth that is demonstrating technology for client care. While touring the booth, the nurse meets an informatics nurse specialist (INS). Being unfamiliar with this position, the nurse asks the INS, "How did you get this position?" Which response by the nurse would be most appropriate?

"I've had graduate-level education focusing on informatics."

How does Hypocalcemia most commonly effect an EKG reading? (What segment or interval is effected and how)

Lengthening of the ST segment or prolongation of the QT interval

A nurse is practicing imagery to relieve stress. What might accompany the imagery to even further promote relaxation?

Listening to music

Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls?

Lock wheels on beds and wheelchairs.

Which of the following people has the greatest risk for accidental injury?

A worker who operates industrial machines

Which philosophy underlies the use of CAM?

The mind, body, and spirit function as a unified whole.

A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of which of the following pain syndromes?

Trigeminal neuralgia

Standard precautions should be used:

with every patient. Every time.

Portal of Exit

•Excretions •Secretions •Skin •Droplets

A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client?

"Increase fluids and high-fiber foods, and use a mild laxative."

The home health nurse is admitting a client to the service for complications related to multiple sclerosis (MS) and the client asks the nurse to explain the use of complimentary health approaches. The client states, "All of the medication I am taking is making me sicker. There has to be a better way." What is the best response by the nurse?

"We can discuss with your health care provider some helpful complimentary therapies."

An informatics nurse is working as part of a team considering an update to a clinical information system already in place. Which questions would be important for the team to ask first? Select all that apply.

"What is the purpose of the change?" "Will it improve overall usability?" "How will its use be incorporated into the nurse's current workflow?"

A nurse is teaching an alert client how to use a PCA system in the home. How will the nurse explain to the client what they must do to self-manage pain?

"When you push the button, you will get the medicine."

A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia?

"You will be awake and will not have sensation of the procedure."

Which questions asked by the nurse when taking a client's health history would collect data about infection control?

'When did you complete your immunizations?"

droplet viruses include:

-Adenovirus (respiratory virus) -Influenza -Mumps -Rubella -Parvovirus B-19

For patients known or suspected to have diseases transmitted via direct contact. High level of HAI's

-Clostridium difficile (C-diff) -Methicillin-resistant Staphylococcus aureus (MRSA) -Vancomycin-Resistant Enterococcus (VRE) -Multidrug resistant organisms (MDRO)

droplet bacteria include:

-Diphtheria -Pertussis -Streptococcal pharyngitis -pneumonia

To break this link of Reservoirs:

-Healthy employees (immunizations) -Environmental sanitation -Disinfection/Sterilization

Preventions for Mode of Transmission

-Isolation -Proper food handling -Airflow control -Standard precautions -Sterilization -Hand Hygeine

Airborne illnesses:

-Measles -Varicella -Tuberculosis (Implement negative pressure in room)

To break the link of Portal of Entry

-Wound care -Catheter care -Aseptic technique

The physician's admitting orders indicate that the client is to be placed in Fowler position. Upon positioning this client, how much will the nurse elevate the head of the bed?

45 to 60 degrees

A nurse is researching a standardized herbal supplement to help a client with pain. What does the word standardized mean?

It contains a certain amount of an active ingredient.

A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man?

Airborne route

A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus?

Alcohol consumption and smoking

An informatics nurse is assisting with the development of a new clinical information system that will be implemented in the facility. As part of the process, the team is evaluating the purpose of the system and the technological options available. The team is in which phase of the system development lifecycle?

Analyze and plan

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which agent is most likely the cause of the infection?

Bacteria

Isoelectric line

represents the baseline electrical activity of the heart

An informatics nurse specialist is working with a team who is developing an expanded system for documenting critical values in the electronic health record (EHR) being used at the facility. The team has identified the need for this addition and provided appropriate evidence to support this change. The team would now proceed to which phase in the system development lifecycle?

Design and build

A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called "the kissing disease." The nurse explains that the organisms causing this disease were transmitted by:

Direct contact

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, which postoperative intervention would be included on the plan of care?

Monitor respirations and breath sounds.

Susceptible Host

•Immuno-compromised •Diabetes •Surgery patients •Burns •Elderly

A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain?

Endorphins

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's

A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this intervention?

Gate control theory

A nurse is using a technique that involves the five senses to visualize recovering from an upcoming surgical procedure. What type of technique is the nurse teaching the client to use?

Guided imagery

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request?

Inform the physician that it is his responsibility to obtain the signature.

A nurse asks a client to rate his pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. What characteristic of pain is the nurse assessing?

Intensity

Portal of Entry

•Mucous membranes •GI tract •GU tract •Respiratory tract •Broken skin

Reservoirs

•People •Equipment •Water

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall?

Orient the client to the room and environment upon admission.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following?

Paralysis of the legs

How does Hyperkalemia most commonly effect an EKG reading?

Peaked T waves

Which essential oil can be used during aromatherapy to treat nausea?

Peppermint

An informatics nurse is part of a team that is testing a new electronic health record system. The testing involves large groups of health care providers who will be using the system. During this testing, the system stalls and fails to respond when large numbers of providers are using the system at the same time. Which phase of testing is being conducted?

Performance

An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse?

Report suspicions about the abuse to proper authorities.

Using a fire extinguisher

•Pull •Aim •Squeeze •Sweep

A. Isoelectric line B. P-wave C. QRS complex D. T-wave

Please match sections with labeled EKG graph directly next to the segment or wave.

Of all possible nursing interventions to break the chain of infection, which is the most effective?

Practicing hand hygiene

There are three phases of involved in perioperative nursing care

Pre-Operative • Intra-Operative • Post-Operative

A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain?

Referred

Response to a fire

•Rescue •Alarm •Contain •Extinguish •Relocate

Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for Suffocation

What wave, interval, complex or segment is important to understand when evaluating for a Heart attack/MI - STEMI

ST segment

A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs?

Soil

A client is very anxious and states, "I am so stressed." What is the reason stress affects the client's safety?

Stress tends to narrow the attention span

What type of nonpharmacologic pain relief measure uses electrical stimulation to inhibit transmission of painful impulses?

TENS. Transcutaneous Electrical Nerve Stimulation. Transcutaneous means "across the skin". In simple terms, a tens machine stimulates your nerves via an electrical current through your skin. A TENS machine is an electronic medical device.

A nurse practices holistic client care. Which of the following is a guiding principle of this practice?

The body is a unified, dynamic whole.

A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. What is a recommended guideline for initiating this training?

The child should be able to communicate the need to void.

A nurse who is a traditional Chinese medicine practitioner is providing home care to a client who also uses traditional Chinese medicine for health care. What specific assessments would the nurse make?

Tongue and pulses

A nurse is reading a journal article about nursing informatics in which the article describes the two types of nurse informaticists. The nurse demonstrates understanding of the article by identifying which characteristic as being solely reflective of an informatics nurse (IN)?

The nurse has received primarily on-the-job training.

A nurse practitioner uses integrative care in his practice. What does this mean?

The nurse uses both allopathic medicine and CAM.

A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication?

The urine may be brown or black.

A trained nurse uses the technique of "Rolfing" to break up tension in client body structures. What type of CAM is being used by this nurse?

Therapeutic massage

The client lives in a remote area and has been referred to a specialist who travels to the area once a month. The client's condition requires an appointment as soon as possible. The low-income client has no reliable transportation. What would the nurse do to facilitate access to the specialist for the client?

Use videoconferencing to access the specialist.

A facility is planning to implement an update to the electronic health record. This update is designed to facilitate documentation of critical changes in clients' condition to save time that nurses spend when documenting these changes. An informatics nurse specialist asks a group of staff nurses to test this update to determine if it is working as it was designed. The nurses are involved in which type of testing?

User acceptance

A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted?

Vectors

Which description defines an infection?

a disease resulting from pathogens in or on the body

Whenever you see bleeding or low blood pressure

assume that you need to give fluids.

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for:

cardiac problems.

P wave

depolarization of the atria

QRS complex

depolarization of the ventricles

micturition

emptying the bladder

Which intervention is of major importance during preoperative education?

encouraging the client to identify and verbalize fears

Which is an example of the body's defense against infection?

immune response

A nurse is assessing the urine on a newborn's diaper. What would be a normal assessment finding?

light in color and odorless

Which consideration should a nurse prioritize relating to the use of herbs and supplements by a client?

potential interactions with drugs

A college-aged student has influenza. At what stage of the infection is the student most infectious?

prodromal stage

The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process?

prodromal stage

T wave

repolarization of ventricles

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides . The nurse informs the group that back stress and injury can be prevented by:

spreading the feet shoulder-width apart to broaden the base of support.

During a visit to the pediatrician's office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when:

the child can recognize bladder fullness.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the client's ability to assist

Most common causative agents

•Bacteria •Fungi •Viruses •Rickettsia •Protozoa

Chain of Infection

•Causative agent •Reservoir •Portal of exit •Mode of transmission •Portal of entry •Susceptible host

Mode of Transmission

•Direct contact •Ingestion •Fomites •Airborne •Droplets

How do you treat bleeding

•Identify the source of the bleeding •Apply direct pressure •Bolster the dressing, do not change it