Fundamentals EAQs

To institute appropriate isolation precautions, the nurse must first know the

-Organism's mode of transmission *e.g. nasal secretions=respiratory isolation (private room, gown, mask, gloves) *A nurse also needs to know the organism's susceptibility to antibiotics, but this could take too long and does not prevent transmission possibilityies

Wrong size BP cuff

-retake the BP using right cuff, educate on why the wrong cuff produces the wrong reading

How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

-Draw up the regular insulin, then NPH in the same syringe *drugs that are compatible may be mixed together in one syringe. The regular insulin is shorter acting and should be drawn up first to ensure accurate measurements.

A nurse needs to provide preventive and primary care to adults during a health camp. Which of these actions should the nurse perform? Select all that apply.

-The nurse should discuss vaccinations -The nurse should discuss family planning -The nurse should instruct the health camp about road safety measures **Day care services and self-care interventions are part of the restorative care level, not preventative and primary

What points should the nurse remember when caring for a client who has a history of suicide attempts? Select all that apply.

-The nurse should document any measures taken to prevent suicide -If the client makes a suicide attempt in the hospital, this may lead to a lawsuit -The primary health care facility will be responsible for failure to provide adequate supervision

Which terms might the nurse use to describe a client who was born a man but lives as a woman? Select all that apply.

-Transgender -Transwoman

The nurse administrator is assessing the quality of health care provided by the nursing team in a health care center using the Donabedian model of care quality. What components should the nurse assess while evaluating the "process" of the health care delivery system? Select all that apply.

-Whether the nurses work in coordination with one another -Whether the nurses Are providing adequate client education Donabedian model of quality care includes the structure, process, and outcome aspects of quality of care. Process portion includes what is being done and what happens in the medical interaction, both technically and medically

A patient is characterized with a #16 indwelling urinary (foley) catheter to determine if:

His 24-hour output is adequate *a 24-hr urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, UTI, or residual urine.

The physician's order reads "Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 min. what is the flow rate if the drop factor is 10 gtt = 1 ml?

25 gtt/min total volume / time * drop factor

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to?

A blended family

When caring for a client with venous insufficiency, the nurse would implement which nursing measure?

Elevate the clients legs above the heart This allows for gravitational force to make the blood flow towards the heart from lower extremities. Otherwise, blood can pool in the legs causing swelling or pain and sometimes leakage and ulcers.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

Elevate the head of the bed between 30 and 45 degrees

After having an IV line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the IV site reveals that it is warm and erythematous. This usually indicates

Phlebitis (inflammation of a vein) *infection is less likely because no drainage or fever is present *infiltration would result in swelling and pallor *no indication of bleeding

Which feature is most likely related to entry-level nurse competencies?

Working as a team member and collaborating with other team members

An autoclave is used to sterilize hospital supplies because

-Pressurized steam penetrates the supplies better *this makes it better at destroying all forms of microorganisms, including spores

A nurse is educating an older adult for the purpose of promoting wellness. What instruction should the nurse give to reduce the risk of disability?

"Engage in physical activities to stay fit"

the most important nursing intervention to correct skin dryness is:

-encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas *dry skin will eventually crack, making the patient more prone to infection. nonirritating soaps, hydration, and lubricating the skin can help prevent this. *bathing may be limited but need not be avoided entirely *the attending physician and dietician may be consulted for treatment, but home laundered items are usually not necessary

Patient interview process

-introduce yourself -chief complaint -history of present illness (if appropriate, not applicable for check up) -past medical history -past surgical history -family history (history of all illnesses, including mental, in family members) -social history (domestic violence, alcohol, drug use, mental health) -review of systems (think of docucare)

Restraints can be used for all of the following purposes except to:

-prevent a patient from becoming confused or disoriented *by restricting a patient's movements, restraints may increase stress and lead to confusion, rather than prevent it

A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many ml should the nurse administer?

0.5 ml

Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:

Having the patient take a 30-60 minute nap in the afternoon napping in the afternoon is not conductive to nighttime sleeping. quiet music, watching tv, reading, and massages usually will relax the patient, helping them to fall asleep

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing?

Hyponatremia normal blood sodium levels should be between 135 and 145 mEq/L. Anything below is considered hyponatremia, anything above is considered hypernatremia

While performing the discharge assessment of a client who has undergone abdominal surgery, the nurse finds that the client exhibits good health and is able to perform activities without assistance. Which nursing action during the discharge indicates failure to promote appropriate continuity of care?

The nurse asks the client to get a chest x-ray in one week. Nothing about his current progress indicated a lung pathology concern, does not require a chest x ray

What does the nurse recognize as the reason the faucet handles on the sinks in a client's room are considered contaminated?

They are touched by dirty hands when turning the water on

The natural sedative in meat and milk products (esp. warm milk) that can help induce sleep is

Tryptophan Flurazepam (dalmane), temazepam (restoril), and methotrimeprazine (levoprome) are hypnotic sedatives

Which of the following is the nurse's legal responsibility when applying restraints?

-All of the above: Document the patient's behavior, Document the type of restraint used, Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others

A nurse caring for a patient with an infectious disease who requires isolation should refer to guidelines published by the:

-Center for Disease Control (CDC) *The CDC publishes and frequently updates guidelines on caring for patients who require isolation *the NLN's major function is accrediting nursing education programs in the US *The AMA is a national organization of physicians *The ANA is a national organization of registered nurses

The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient's first priority concerning self injection in this situation is to:

-Check the syringe to verify that the nurse has removed the prescribed insulin dose *When the nurse teaches the patient to prepare an insulin injection, the patient's first priority is to validate the dose accuracy. The next steps are to select the site, asses the site, and clean the site with alcohol before injecting the insulin

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply.

-Dry cleaners -Dye workers

Which of the following symptoms is the best indicator of imminent death?

-Fixed, dilated pupils *pulse becomes weak but rapid, muscles become weak and atonic, and periods of apnea occur during respiration

Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

-Have the patient expectorate the sputum into a sterile container to ensure no contamination

Which questions should the nurse ask to elicit psychosocial issues in a client with cancer? Select all that apply.

-How is your family dealing with your condition? -How do you rate your distress on a scale of 1-10?

When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique

-Increases venous blood return *thereby preventing venous stasis. It improves circulation but does not result in vasoconstriction *the nurse can assess the patient's condition throughout the bath, regardless of washing technique, and should feel no strain while bathing the patient

A patient just received 30 mg of codeine by mouth for pain. 5 minutes later he vomits. What should the nurse do first?

-Observe the emesis to document color, consistency, and amount as well as checking for remnants of the medication to help determine whether the patient retained enough of it to be effective. The nurse should then contact the physician.

Nurses and other health care provers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

-Reflecting on the significance of death *according to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient's feelings. It also helps to overcome the belief that medical and nursing measures have failed when a patient cannot be cured

What services does block and parish nursing provide for preventive and primary care services? Select all that apply.

-Respite care -Running errands -Homemaker aides

A nurse is educating a client about the tertiary level of prevention. What information should the nurse provide? Select all that apply.

-Tertiary prevention focuses on preventing complications of an illness -tertiary prevention helps clients achieve as high level of functioning as possible -Tertiary prevention aims at minimizing the effects of long-term disease or disability

A nursing student is listing the characteristics of the maintenance stage of health behavior change. Which points mentioned by the nursing student are accurate? Select all that apply.

-The client can sustain health behavior changes over time -The client feels the need to integrate changes into his or her lifestyle -The client reaches this stage 6 months after engaging in action and continues the changes indefinitely

UAP responsibilities

-can take vital signs, cannot interpret results -can measure but not interpret

Kubler-Ross's five successive stages of death and dying are:

-denial, anger, bargaining, depression, acceptance *the patient may move back and forth through the different stages as he/she and the family members react to the process of dying, but he usually goes through all of these stages to reach acceptance

A nurse is evaluating different situations related to obtaining informed consent. Which situation does the nurse consider to be the most appropriate method of obtaining informed consent?

A client provides consent after the healthcare provider has given a detailed explanation of the risks, benefits, and alternatives to the procedure

The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to

Gently pull just below the cuff and invert the gloves when removing them *Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should then be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged)

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to?

Explanation Analysis=assessing whether the obtained information is true Evaluation=Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions. Interpretation=Being orderly in data collection and looking for patterns to categorize data

A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

Making changes after evaluating the situation and having discussions with the staff *

A terminally ill patient usually experiences all of the following feelings during the anger stage except:

Numbness *numbness is typical of the depression stage when the patient feels a great sense of loss. the anger stage includes feelings such as rage, envy, resentment, and questioning "why me?"

Vivid dreaming occurs in which stage of sleep?

Rapid Eye Movement (REM) stage other characteristics of REM sleep are deep sleep, depressed muscle tone, and possibly irregular heart and respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming -Delta stage (slow-wave sleep) occurs during non-REM stages III and IV and is often equated with quiet sleep

Client A is recovering from heart surgery and needs to adapt to his or her environment. Client B is at the last stage of cancer. Which of these theories may the nurse use for better health maintenance of both the clients?

The nurse may use Roy's theory for client A and Henderson's theory for client B. Roy's theory emphasizes adaptation to the surroundings. For example, a client who just had heart surgery should be told to take the prescribed medication, follow a proper diet, and exercise daily for a fast recovery. Henderson's theory describes the role of a nurse in assisting the client to perform daily activities that will contribute to recovery or a peaceful death. For example, a nurse may try to improve the morbid condition of an end stage cancer client to have an inevitable peaceful death

What was the underlying purpose of the national health information technology infrastructure that originated from the Executive Order Incentives for the Use of Health Information Technology issued by President George W. Bush in 2004?

To improve the quality, safety, and efficacy of healthcare. This was to be achieved by mandating healthcare facilities to use electronic client records

To ensure homogenization when diluting powdered medication in a vial, the nurse should:

Roll the vial gently between the palms. *this produces sufficient heat to enhance dissolution of a powdered medication *shaking the vial vigorously can break down the medication and alter its pharmacologic action *inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern?

The baby has a head lag when pulled to sit