Final Exam - NUR113 SP20
A nurse is explaining an electromyography (EMG) to a client. The nurse would be correct in stating which of the following about an EMG?
"The test will monitor brain waves" Electroencephalography (EEG) is a diagnostic test that monitors brain waves. "You will feel nothing" A needle is inserted into a muscle, which will cause a sting to the client. The client will then contract the muscle, which will record an electrical response. "It will be used to watch the electrical response of your muscles During electromyography (EMG) electrodes are placed in the muscles and the client will contract that muscle while the electrical impulses are recorded. "You will need local anesthesia prior to the test" No anesthesia is used for electromyography (EMG). For an EMG, the client does not need to require any anesthesia. It is done while the client is under no anesthesia so that muscle responses occur and correct electrical responses are recorded.
A nurse practitioner assesses a patient's movement in his left hand after a cast is removed. The nurse asks the patient to turn his wrist so the palm of his hand is facing up. This movement is known as:
***Refer to Figure 40-3 in the text for an illustration of body movements produced by muscle contraction.
A nurse is providing instructions to a client who is undergoing a thoracentesis to assess for malignant tissue. The nurse should instruct the client to do which of the following related to the procedure? Select all that apply.
Position the client upright with trunk slightly forward A thoracentesis involves the removal of fluid, air or tissue from the pleural space. It involves aspiration using a needle. The nurse should position the client sitting upright and slightly forward with arms resting on a bedside table. The client should be provided pain medication as needed, and encouraged not to cough, deep breathe or move during the procedure. After the procedure, the puncture site must be dressed with a pressure dressing and monitored for bleeding and crepitus. Ensure client does not cough or deep breathe during the procedure A thoracentesis involves the removal of fluid, air or tissue from the pleural space. It involves aspiration using a needle. The nurse should position the client sitting upright and slightly forward with arms resting on a bedside table. The client should be provided pain medication as needed, and encouraged not to cough, deep breathe or move during the procedure. After the procedure, the puncture site must be dressed with a pressure dressing and monitored for bleeding and crepitus. Assess the site for crepitus post-procedure A thoracentesis involves the removal of fluid, air or tissue from the pleural space. It involves aspiration using a needle. The nurse should position the client sitting upright and slightly forward with arms resting on a bedside table. The client should be provided pain medication as needed, and encouraged not to cough, deep breathe or move during the procedure. After the procedure, the puncture site must be dressed with a pressure dressing and monitored for bleeding and crepitus. Lie in the side-lying position for ten minutes after the procedure The client should be positioned side-lying on the unaffected side for one hour following the procedure. Perform diaphragmatic breathing exercises for 30 minutes following the procedure The client should be instructed to breathe normally while the puncture site heals for one hour to avoid any stress on the area. The puncture side will heal rapidly and the client should be able to resume normal activity in one hour.
A client is prescribed a sulfonamide. The nurse notes that the client also takes warfarin. The nurse notifies the healthcare provider because of which effect that will occur when these two medications are taken concurrently?
Warfarin effects are increased Sulfonamides cause increases in warfarin effects. Warfarin effects are decreased Sulfonamides cause an increase in warfarin effects. Sulfonamide effects are increased Sulfonamides cause an increase in warfarin effects. Sulfonamide effects are decreased
A client is diagnosed with a fracture of a diarthrosis joint. What is an example of this type of joint?
A diarthrosis joint, like the elbow, is freely movable. The skull is an example of an immovable joint. The vertebral joints and symphysis pubis are amphiarthrosis joints that have limited motion.
Which statement describes paresthesia?
Abnormal sensations -Abnormal sensations, such as burning, tingling, and numbness, are referred to as paresthesias. The absence of muscle tone suggesting nerve damage is referred to as paralysis. A fasciculation is the involuntary twitch of muscle fibers. A muscle that holds no tone is referred to as flaccid.
A nurse is giving a client education on tetracycline use and asks about other medications that the client takes. The nurse would be concerned by which of the following other medications being used with tetracyclines? Select all that apply.
Antacids Antacids interact with tetracyclines. Antacids and iron make tetracyclines not as effective and tetracyclines will increase in bleeding time so caution needs to be taken for a client on anticoagulants. Probiotics This does not interact and would be good for the client to take since tetracyclines and alter the intestinal flora. Oral anticoagulants Oral anticoagulants interact with tetracyclines. Antacids and iron make tetracyclines not as effective and tetracyclines will increase in bleeding time so caution needs to be taken for a client on anticoagulants. Iron Iron preparations interact with tetracyclines. Antacids and iron make tetracyclines not as effective and tetracyclines will increase in bleeding time so caution needs to be taken for a client on anticoagulants. Tylenol This does not interact with tetracyclines.
A patient is scheduled for a procedure that will allow the physician to visualize the knee joint in order to diagnose the patient's pain. What procedure will the nurse prepare the patient for?
Arthroscopy is a procedure that allows direct visualization of a joint through the use of a fiberoptic endoscope. Thus, it is a useful adjunct to diagnosing joint disorders.
Which of the following is an example of a hinge joint?
Hinge joints permit bending in one direction only and include the knee and elbow. The hip is a ball-and-socket joint. The joint at the base of the thumb is a saddle joint. Gliding joints allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist.
A client with a sports injury undergoes a diagnostic arthroscopy of the left knee. What comment by the client following the procedure will the nurse address first?
Numbness would indicate neurological compromise of the extremity and requires immediate intervention to prevent permanent damage. An aching knee is expected after the procedure. Cold or swollen feet are not priority assessments.
The nurse just completed a series of practice drills with the local emergency team. Which of the following stages of emergency management is the nurse currently in?
Response Response is live action to an event. Recovery Recovery is the phase where rebuilding takes place. Preparedness Practice drills are necessary preparation. Prevention Prevention is the phase during which community education takes place.
The nurse is caring for a client who is experiencing urinary retention. Which intervention is appropriate to help this client to void?
Set a goal with the client to urinate in a specific amount of time When a client has urinary retention, putting pressure on the client to urinate in a specific time frame is not helpful. Encourage rest The nurse should encourage the client to ambulate, because being active will promote urination. Encouraging the client to be sedentary could worsen the urinary retention. Encourage fluid intake The client is more likely to urinate with a full bladder than an empty bladder, and moving fluid through the bladder is important for kidney function as well as preventing a urinary tract infection. Be present with the client while the client attempts to void The client should be provided with privacy to facilitate voiding.
Which term refers to the shaft of the long bone?
The diaphysis is primarily cortical bone. -An epiphysis is an end of a long bone. Lordosis refers to an increase in lumbar curvature of spine. Scoliosis refers to lateral curving of the spine.
Which of the following is an appropriate priority nursing diagnosis for the client following an arthrocentesis?
The priority nursing diagnosis following an arthrocentesis is risk for infection. The client may experience acute pain. The client needs adequate information before experiencing the procedure. Activity intolerance would not be an expected nursing diagnosis.
An example of a flat bone is the
sternum -An example of a flat bone is the sternum. A short bone is a metacarpal. The femur is a long bone. The vertebra is an irregular bone.
A nurse is caring for a client with type 2 diabetes who has been prescribed an incretin mimetic medication for blood glucose control. Which medication is an example of an incretin mimetic?
Exenatide (Byetta) An incretin mimetic medication is used for blood glucose control among clients with type 2 diabetes. This type of drug is given as an injection to stimulate the body to secrete insulin after eating. It also decreases the amount of sugar the liver makes and slows down food digestion in the stomach. Rosiglitazone (Avandia) This drug is a thiazolidinedione antidiabetic agent, not an incretin mimetic. Chlorpropamide (Diabinese) This drug is a sulfonylurea, not an incretin mimetic. Metformin (Glucophage) This drug is a biguanide, not an incretin mimetic.
The nurse is assessing a client's ulnar nerve. What technique will the nurse use?
To assess the ulnar nerve, the nurse would prick the distal fat pad of the small finger.
The nurse is caring for a client who will undergo a procedure of the eye. The nurse recognizes that which of the following drugs will cause ciliary body paralysis?
Homatropine This medication is a cycloplegicmydriatic that paralyzes the ciliary body muscles. It is used to dilate the eye, reduce eye pressure after a procedure, or treat certain eye conditions. Phenylephrine This is a decongestant for the nasal passages. Diamox This is a medication to reduce pressure in glaucoma, but does not paralyze the ciliary body muscles. Cromolyn This drug is reduces allergy symptoms in the eye
The nurse is preparing to administer sumatriptan for the management of a migraine headache. By what route should the nurse give the medication? Select all that apply.
Orally This is an appropriate rout of administration for sumatriptan. Intramuscularly This route is not utilized for the administration of sumatriptan. Subcutaneously This is an appropriate rout of administration for sumatriptan. Sumatriptan is a serotonin receptor agonist. The most relief is found when this drug is given via the subcutaneous route. However, this route is also associated with the most reported adverse effects. Rectally This is an appropriate rout of administration for sumatriptan. Intranasal spray This route is not utilized for the administration of sumatriptan
Which of the following is the most common site of joint effusion?
The most common site for joint effusion is the knee. If inflammation or fluid is suspected in a joint, consultation with a provider is indicated. The elbow, hip, and shoulder are not the most common site of joint effusion.
A nurse is reviewing a physician's order for medications to ensure that the nurse followed directions correctly. Select all of the following abbreviations that are correctly paired with their meanings.
Tid: three times per day A physician, when writing drug orders, may use certain approved abbreviations as part of the prescription. The nurse should be familiar with what certain abbreviations mean. As an example, tid stands for three times per day, A: after "a" stands for before, and "AU" is the abbreviation for both ears. The symbol for after is "p" PR: rectal While PR means per rectum. AU: right ear The right ear is "AD" (auris dextris). OS: left eye OS stands for left eye, or "oculus sinister".
Which of the following would be considered a role of a nursing mentor?
Being a real-life role model to influence the work of one or more nurses Within nursing, a mentoring relationship develops between a nurse with more experience and a nurse with less experience and knowledge. Nurse mentors do not have to be managers or in positions of authority in the workplace. A mentoring relationship can be informal, in which a seasoned nurse passes on important knowledge and wisdom to a nurse who is new or who is learning. Providing education about staff policies to a new nurse on the unit This describes the role of a nurse educator. Leading a presentation about standards of care at the monthly staff meetings This could be done by a staff member who is also involved in a committee, or passionate about a certain nursing topic. Being available to discuss conflicts that affect the nursing staff This describes the role of the unit manager.
Which of the following medications are for thyroid regulation?
Levothyroxine This is a medication that communicates to the body to release thyroid stimulating hormone (TSH). Metoprolol Metoprolol is a beta blocker that is given for hypertension. Lisinopril Lisinopril is an ACE inhibitor that is given for hypertension. Rifampin Rifampin is an antibiotic used to treat TB.
The nurse receives a client with altered mental status from the ambulance. What is the first thing the nurse will obtain?
Check vital signs Airway, breathing, and circulation always come first. Since these are not answer options, the correct answer is vital signs, because blood pressure, respirations and pulse oximetry will give information on breathing and circulation status. Check glucose Altered mental status could be due to hypoglycemia, but this is not the first intervention the nurse will perform. Vital signs are first, followed by a quick pupil check and then glucose would be checked. Get a head CT This is a lower priority intervention than simple vital signs. Vital signs are first, and if the provider orders a head CT, this will be done after the vital signs, glucose check, and pupil check. Check pupils Pupils will be quickly checked on the initial assessment, but vital signs are first. Checking pupils would be done second.
The nurse is caring for a client that is receiving aminoglycoside. The nurse knows to assess the client for which of the following adverse effects?
Nephrotoxicity This is an adverse effect of aminoglycoside use. The client should be watched for nephrotoxicity which would present as decreased urinary output, fluid retention, nausea, weakness, and confusion. Ototoxicity This is an adverse effect of aminoglycoside use. Ototoxicity would present as hearing problems, ringing in the ears, and balance problems. Vomiting As this could occur but is not an adverse effect related to aminoglycoside use. Fever As this could occur but is not an adverse effect related to aminoglycoside use. Heart burn As this could occur but is not an adverse effect related to aminoglycoside use.
The student nurse is discussing ventricular fibrillation with their nursing instructor, the student nurse needs further teaching after which of the following statements about ventricular fibrillation (V-fib) is made?
Not a shockable rhythm This statement requires further teaching, ventricular fibrillation is a shockable rhythm. When a client is in cardiac arrest They are true statements that do not require further teaching Shock immediately They are true statements that do not require further teaching Requires CPR They are true statements that do not require further teaching
What is the purpose of one family member be assigned to receive information?
To prevent communication errors The purpose is to allow one family member to disseminate information to the whole family. Miscommunication could still occur. To disseminate information for the whole family This is the main purpose. It allows one person to communicate with the medical staff. To advise the patient The purpose is for disseminating information. Whether the patient takes advice from this family member or not is up to them. To explain the family's priorities We are concerned with the client and the family member's purpose is to disseminate information
The nurse is caring for 4 clients who all need medication. Which client needs medication first?
Epinephrine for the cardiac arrest client This client is in cardiac arrest, which means the heart has stopped. Epinephrine is given in hopes that the heart will begin beating again. This client is FIRST. Morphine for the chest pain client Chest pain should be emergently assessed and treated, but this client's heart has not stopped. The client in cardiac arrest must be managed first. Albuterol for the asthma attack client An asthma attack impacts the airway, but we are not told that the client is unable to move any air in and out of the lungs. Airway is important, but before medicating this client, the nurse must stabilize the client in cardiac arrest. Acetaminophen for the febrile client The febrile client is stable. This is not the nurse's priority.
A client who is recovering from surgery has been ordered to have a full liquid diet. Which foods can the client eat on this diet? Select all that apply.
Ice cream Foods that are opaque liquid, or liquid at body temperature are part of a full liquid diet. Ice cream, sherbet and milk are included. Strained soup Strained soup is normally liquid, so it is part of the full liquid diet. Cottage cheese This is a soft food but is not considered a liquid. Runny, scrambled eggs This is a soft food, but is not liquid. Pudding A full liquid diet is appropriate for a client who is advancing their diet following a procedure or an illness that affects digestion. This diet includes opaque liquid foods and foods that are liquid at body temperature. This is the next advanced diet after a clear liquid diet. Examples include plain ice cream, sherbet, milk, pudding, custard, strained soups, strained vegetable juices and refined cooked cereal. This diet is deficient in many nutrients and does not typically provide enough calories, so the hope is that the client advances to the next diet stage, mechanical soft, in a timely manner.
The nurse is caring for a client who will have a bedside thoracentesis. The nurse must get the client into the proper position for this procedure. Which position is correct?
Sitting in bed with a table across the client's lap, leaning fully onto the table This is termed the "orthopneic position", and is most appropriate for a thoracentesis. Lying flat with a pillow under the head/shoulders This describes the prone position, and is not appropriate positioning for a thoracentesis. Sitting straight up with the head of bed at 45 degrees This describes the Fowler's position, and is not appropriate positioning for a thoracentesis. Lying flat on the stomach, head to the side This describes the dorsal recumbant position, and is not appropriate positioning for a thoracentesis.
The nurse is caring for client with diabetes. Which of the following are appropriate nursing interventions? Select all that apply.
Maintain a low protein diet The client should be encouraged to limit carbohydrates, but protein is essential for a balanced healthy diet in the client with DM. Give lipid lowering medications if indicated Lipid lowering medications are often necessary for a client with diabetes mellitus. Teach the client about the glycemic index The diabetic client should have a balanced diet with all essential food constituents, be on lipid-lowering medication if indicated and should be encouraged to engage in some form of aerobic exercise. Encourage high caloric intake The client with diabetes mellitlus should eat enough calories to maintain an ideal weight, but not a high-calorie diet. Encourage aerobic exercise A client with diabetes needs to be careful when first beginning an exercise program, in order to understand how the body's blood glucose level responds to exercise, but exercise is beneficial for a client with this condition.
The provider orders an electrolyte replacement on a client with a potassium of 2.4. The nurse knows that this potassium level could be caused by which of the following?
Vomiting Normal potassium levels in the blood are between 3.5-5.5 mEq/L, so this client is hypokalemic. Vomiting can lead to potassium loss. Diarrhea Normal potassium levels in the blood are between 3.5-5.5 mEq/L, so this client is hypokalemic. Diarrhea can lead to potassium loss. Loop diuretics Normal potassium levels in the blood are between 3.5-5.5 mEq/L, so this client is hypokalemic. Loop diuretics decrease potassium levels. Dehydration This can cause an increase in serum potassium, not a decrease. Excess potassium intake This would increase the level of potassium, not decrease it.
A client with potential rheumatoid arthritis is having laboratory testing and requires an ESR blood test. Which of the following best describes the ESR?
he rate at which blood cells settle to the bottom of a tube containing blood A client with rheumatoid arthritis may have a laboratory test of an ESR (erythrocyte sedimentation rate), or 'sed rate' to determine the amount of inflammation present. Inflammation causes red blood cells to clump. When the cells clump, they become denser and sink to the bottom of the tube more quickly. The ESR is the rate at which blood cells settle to the bottom of a tube containing blood. The amount of by-product produced with muscle breakdown This describes a creatinine level, not the ESR. The level of antibodies present in response to an inflammatory antigen This describes a person's immune response, not the ESR. The presence of a gene that increases rheumatoid factor The ESR is the rate at which red blood cells clump and turn to sediment at the bottom of a tube. It does not reveal genes related to RA.
The triage nurse has 4 clients in the waiting room with one bed open in the emergency department. All client's ABCs (airway, breathing, circulation) are intact and their vital signs are within normal limits. Which client is the priority to bring bac
98 year old male with abdominal pain All clients are relatively stable, and none have life-threatening symptoms. The client with abdominal pain is advanced in age, which makes him more likely to deteriorate quickly. This client should be seen first. 43 year old female with right arm pain This client does not need to be seen first, as she is stable with no indications of deterioration. 25 year old male with a Crohn's flare up This client has a chronic condition, but is stable and does not need to be seen first. 17 year old female with a laceration, bleeding controlled This client is stable since the bleeding is controlled, but she should be seen second because of the infection risk of an open wound. Recommended NURSING.com Stu
A nurse administers digoxin (Lanoxin) to a client with heart failure. Based on the nurse's knowledge of this drug, which intervention should the nurse perform before administering it?
Check the client's heart rate Digoxin is a medication used in the treatment of heart failure, and it works by affecting sodium and potassium inside heart cells. This helps the heart maintain a normal, steady and strong heartbeat, reducing strain on the heart muscle. The nurse should not give the drug without first checking the client's pulse. After administering digoxin, the nurse monitors the client for a slowed heart rate. Assess the client's lung sunds This assessment is imporotant in the client with heart failure, they are not part of the nursing assessment related to administering digoxin. Monitor the client's oral intake This assessment is important in the client with heart failure, they are not part of the nursing assessment related to administering digoxin. Assess for pitting edema This assessment is important in the client with heart failure, they are not part of the nursing assessment related to administering digoxin
The Chief Nursing Officer institutes a Nursing Shared Governance Council in their facility. Which of the following statements best describes the primary purpose of a shared governance council?
Discuss behavioral and disciplinary issues within the units This is a primary function of the management team within each specific unit. Ensure compliance with annual mandatory education The unit educator is responsible for this. Though the Shared Governance Council may promote education initiatives, basic mandatory education compliance is not within their scope. Perform service projects on hospital units Though the Shared Governance Council may promote service projects as part of their practice, it is not the primary function of the council. Make decisions regarding standards and quality of care Shared governance is a system implemented in some facilities that involves electing team members to work in leadership capacities. These leaders work together to make decisions for the unit or the involved area. Some concepts that may be developed and implemented through shared governance include practice and standards, scheduling, client outcomes, and problem solving. Shared governance can have a positive impact on productivity within the governed area and may increase nurses' feelings of autonomy in their work.
Which of the following changes in elimination would most likely occur in a client who is unable to get out of bed and is immobile? Select all that apply.
Positive nitrogen balance The immobile client experiences nitrogen depletion. Urinary stasis The ability to be mobile helps facilitate urine flow. When a client is immobile, urinary stasis occurs. Increased risk of kidney stones Kidney stones increase in likelihood in the client who is immobile. Diarrhea The immobile client is more likely to experience slowed motility and constipation. Urinary tract infections Immobility affects nearly every organ system, including the cardiovascular, musculoskeletal, respiratory, central nervous, gastrointestinal, and genitourinary systems. The increased risk of renal stones and urinary stasis lead to more frequent urinary tract infections.
There are four clients in the preoperative holding area who are scheduled for a procedure under moderate sedation. The nurse knows that a client with which of the following would be most concerning to the anesthesiologist for proper ventilation during the procedure?
A surgical history of a tonsillectomy This client with the given information does not have ventilation concerns. Previous cervical fusion and BMI of 35 Neck extension issues and elevated BMI can create ventilation concerns. This is more weight around the neck and more weight on the client as well as a cervical fusion that might make tilting the head difficult. A BMI of 20 and missing teeth Even though this client does have missing teeth which can create issues with ventilation, the client with a cervical infusion would have concerns about neck extension for proper ventilation as well as increased weight. History of ovarian cancer and hypertension This client with the given information does not have ventilation concerns. Ventilation concerns would be a client that has a cervical fusion and elevated BMI.
Which of the following would be an example of an autolytic debridement of a lower leg wound in a diabetic client?
Application of a hydrocolloid dressing on the wound An autolytic debridement is a form of tissue removal from a wound that uses the client's own body processes to break down necrotic tissue so that is can be cleared away. The nurse applies a dressing to the wound site, such as a hydrocolloid dressing, which provides a moist environment as the body softens the wound edges. This makes the necrotic tissue easier to remove when the dressing is later taken off. Use of medical-grade maggots to clean the wound This type of debridement, sometimes used for non-healing diabetic wounds is termed "biodebridement". Application of the enzyme papain/urea foam This is a type of enzymatic debridement. Selective removal of tissue with a laser This refers to laser debridement, sometimes used in burn clients.
Which best describes reflexology as a non-pharmacological treatment method that may be utilized for a client suffering from chronic pain?
Applying pressure to sites on the hands, feet, and ears as a method of stress reduction Reflexology is a non-pharmacological method of pain control that may be used for some clients who suffer from chronic pain. Reflexology is performed when a practitioner applies pressure to specific sites in the hands, feet, and ears. The theory is that these points correspond to different organs and parts of the body so that when pressure is applied, the person experiences relief. Using the hands to apply pressure to the joints and sites where the reflexes are present This is not a description of reflexology. Teaching the client how to control certain body functions that are normally not part of his conscious awareness This is not a description of reflexology.
At the end of the shift, a nurse is giving report to the oncoming nurse. The nurse uses the SBAR format to relay appropriate information. The nurse knows that the A in SBAR stands for which of the following?
Assessment The A in the SBAR format stands for assessment. The SBAR format is a method of communicating pertinent information about a client during a handoff or communication with the healthcare provider. It stands for situation, background, assessment, and recommendation. Organizing information through this technique can help to provide a smooth transition when communicating during client handoff. Accept This is not a component of SBAR. Analysis This is not a component of SBAR. As needed This is not a component of SBAR.
A client admitted with diabetic ketoacidosis (DKA) is very upset and concerned because a family member recently had to have an amputation due to diabetes complications. The client asks what can be done to prevent amputation. Which of the following is the best response by the nurse? Select all that apply.
Check your feet daily before bed Diabetics should always check their feet before bed to make sure that they did not injure themselves in any way without realizing it. Remember, diabetics have decreased circulation and sometimes neuropathy so they may not feel things. There is nothing you can do to prevent the complications This is not true. There are ways for the client to help prevent complications such as good control, checking feet before bed, preventing infections, and diet. Take your diabetic medications as prescribed Diabetics should take their medications as prescribed to them to avoid complications. Eat foods high in carbs and sugar. Diabetic clients should not eat foods high in carbs and sugar, but rather they should count carbs and avoid sugar to avoid complications. Wear slippers or shoes around the house Diabetics should wear slippers or shoes around the house to protect their feet. Remember, diabetics have decreased circulation and sometimes neuropathy so they may not feel things.
A nurse is working as a case manager in a long-term care facility. What is an example of a task in the implementing phase of the case management process this nurse would make? Select all that apply.
Delegating tasks for nursing assistants to provide care This intervention is performed by a bedside nurse, but not a case manager. Providing information to residents' families about financial coverage The case management process is somewhat similar to the nursing process, but the case manager tends to perform tasks at a higher level-social services or coordination of care-rather than performing physical tasks or interventions for the client. The case manager's tasks might be coordinating services, providing information, or organizing groups or provider visits. Coordinating provider visits when residents need appointments The case management process is somewhat similar to the nursing process, but the case manager tends to perform tasks at a higher level-social services or coordination of care-rather than performing physical tasks or interventions for the client. The case manager's tasks might be coordinating services, providing information, or organizing groups or provider visits. Organizing a group of health specialists to come to the facility to provide screenings The case management process is somewhat similar to the nursing process, but the case manager tends to perform tasks at a higher level-social services or coordination of care-rather than performing physical tasks or interventions for the client. The case manager's tasks might be coordinating services, providing information, or organizing groups or provider visits.
An HIV-infected client is in the hospital after developing an opportunistic infection. The client's spouse will provide care to the client at home. What information should the nurse provide to the caregiver about providing home care for the client? Select all that apply.
Encourage the caregiver to seek help with client care when necessary Being a caregiver for a loved one with HIV is multifaceted and exhausting, both physically and mentally. The caregiver needs to know how to prevent the client from getting infections, how to prevent the spread of HIV, and how to promote the client's wellness. Additionally, they must attend to their own physical and emotional needs to prevent caregiver burnout. Teach the caregiver to delay getting immunized for the client's sake Due to the decreased immune response of the client, it is very important for the caregiver to stay up to date on immunizations. Remind the caregiver not to share personal tools such as toothbrushes or razors These teaching points will help prevent the client from getting infections. Educate the caregiver to wash fruits and vegetables when preparing food This removes pathogens from food, which is important for the immunocompromised client. Teach the caregiver not to insist the client get out of bed for a day if the client is tired It is important for the client to remain active, or at least get up each day to prevent irreversible deconditioning. The caregiver should encourage the client to remain active as long as they can.
The nurse is caring for a client who has been diagnosed with microcytic anemia by the primary care provider. The client states, "I don't understand why I was diagnosed with anemia." Which of the following options should the nurse communicate to this client?
Nursing Category | Hematologic / Immunology NCLEX® Category | Management of Care The nurse is caring for a client who has been diagnosed with microcytic anemia by the primary care provider. The client states, "I don't understand why I was diagnosed with anemia." Which of the following options should the nurse communicate to this client? Ask the client what event lead to the diagnosis The client in this scenario is admitting a lack of understanding of the condition, or the reason for the diagnosis. The first step the nurse should take is to ask questions to find out what the client knows and does not know rather than assuming the client understands the disease. Ask about paresthesias While anemia can cause paresthesias, this is too specific of a question for the nurse to begin with. The nurse first must gauge understanding before attempting to get specific. Tell the client to eat more spinach and liver While eating more spinach and liver may help the anemia, the goal is to identify what information to give the client first. Teach the client how to cope with fatigue Addressing symptoms is important, but not until the client is satisfied with their own knowledge of the condition.
A nurse is caring for a client that has been diagnosed with pancreatitis. Which of the following is NOT a complication commonly associated with this disease process?
Right lung effusion In pancreatitis, effusions are usually seen in the LEFT lung, not right, because of its proximity to the pancreas. Hypocalcemia Hypocalcemia is common in pancreatitis. It can be related to glucagon-stimulated calcitonin release and decreased PTH secretion. It also has to do with impaired absorption of calcium. Hypovolemia Hypovolemia is a common complication of pancreatitis due to vomiting and poor nutrition. Diseminated intravascular coagulopathy This is a possible complication of pancreatitis. It is thought to be caused by circulating pancreatic enzymes "eating" up coagulation factors, leading to DIC.
A newly diagnosed diabetic client is learning how to give himself insulin injections. The nurse is reviewing the information and the steps of drawing up the insulin. Which statement from the client indicates that more teaching is needed?
Since I'm giving myself a shot, I do not need to wash my hands before giving it." One responsibility of nurses is to provide teaching about the appropriate method of administering insulin when the client must do it himself. The nurse can teach the client that although he is giving himself injections, he still needs to wash his hands to avoid infection or transmission of pathogens. "I can clean the top of this insulin bottle with a little alcohol." This statement demonstrates understanding by the client. "I should clear the air bubbles in the syringe by pushing the plunger instead of flicking the syringe." This statement demonstrates understanding by the client. "Before I draw up the insulin, I will try not to shake the vial too much." This statement demonstrates understanding by the client.
A recovery room nurse is caring for a client who has just undergone a transurethral prostatectomy. The client has continuous bladder irrigation in place. Which of the following is a true statement regarding this type of system? Select all that apply.
The nurse does not need to check intake and output with this system Urine output is an important measurement during CBI. The intake and output of irrigation fluid and urine will be charted. The bladder irrigation prevents clots from forming after surgery A continuous bladder irrigation (CBI) system is one in which a client has a 3-way catheter in place. One tube is for fluid to flow into the bladder, one tube has a balloon to keep the catheter in place, and one tube drains the bladder. This continuous flow of fluid prevents clots from forming and obstructing urine flow out of the bladder. The catheter must be drained and color noted periodically as ordered CBI is often placed just after surgery and used during recovery. The nurse needs to monitor intake and output as well as the quality of the urine, which may contain sediment or appear pink or red. The irrigation system typically produces clear, pale, yellow urine Following bladder surgery there is blood present in the urine so it will appear from dark red to light pink. The system eliminates the need for surgical closure after surgery The purpose of CBI is to prevent clots from blocking the urine flow.
The provider has ordered a nephrostomy tube for a client in the nurse's care. How should the nurse explain the procedure for nephrostomy tube placement to the client?
The tube is placed directly into the kidney to drain urine In nephrostomy tube placement, the tube is placed directly into the kidney in order to drain urine. Any handling of the nephrostomy tube must include strict asepsis by the nurse, since the tube is placed directly into an internal organ. The provider may write an order to irrigate the tube. Irrigation should only be done IF there is an order, using strict aseptic technique, with a maximum of 5 mL sterile normal saline per flush. The tube is placed through the ureter into the renal pelvis The tube enters through the skin in the client's back. The tube is placed into the renal cortex to facilitate excretion The nephrostomy tube terminates in the renal pelvis, or collecting system. The tube is placed in the ureter above the site of the blockage The tube is not placed in the ureter, but enters directly through the kidney.
A nurse is bathing a client who cannot get out of bed. During the bath, the nurse encourages the client to assist with what cares he or she can perform. What is the rationale for this request?
To promote client self-esteem When a client is immobile or is unable to help with cares, he or she may feel discouraged and may struggle with feelings of low self-esteem. During a bath or any other activity of daily living, the nurse should encourage the client to participate as much as possible. Being able to help with cares supports the client's independence and self-esteem. To provide modesty for the client The nurse utilizes a bath blanket to keep the client warm and provide modesty. To prevent the client from becoming chilled The nurse utilizes a bath blanket to keep the client warm and provide modesty. To reduce the spread of microorganisms The bath itself reduces microorganisms on the client. Encouraging the client to assist when possible is not done for the purpose of reducing the spread of microorganisms.
