Funds Test 1

Normal Hematocrit Percentages

Male: 41.5% - 50.4%, Female: 35.9% - 44.6% *The ratio of the volume of red blood cells to the volume of whole blood*

Providing oxygen via a nonrebreather mask is mainly performed when...

The client is conscious

Normal Platelet Count

150 - 400 K/mL Number of platelets in a specified volume of blood.

Which would the nurse consider to be a potential respiratory system-related complication of surgery?

Atelectasis

What is the priority nursing action for a client with delirium?

Creating a calm and safe environment

Which intrinsic factors may contribute to falls in older adults? Select all that apply.

Deconditioning Impaired Vision

Thrombocytopenia

Decreased # of platelets, can cause small blue colored spots due to bleeding from the vessels into tissues.

Which is an example of indirect contact transmission of microorganisms?

Dirty Hands

Plantar warts

Viral

Pruritis

severe itching of the skin

Dyspnea

subjective "I feel short of breath" or can be objective. "Exertional dyspnea"- caused by exercise/increased metabolic rate, increased demand for oxygen. "Conversational dyspnea" - inability to speak complete sentences without stopping to breathe.

Antitussive

suppresses cough. Example: codeine (affects respiratory center, decreases urge to cough)

Oxygen Toxicity

too much of a good thing (more than 50% O2 for longer than 48-72 hours). Cataracts, seizures, shortness of breath, blindness in premature babies put in incubators with high oxygen levels - damaged retinas.

Expectorant

lubricates the irritated respiratory tract, makes it easier to cough up secretions (example: guaifenesin).

Hyperventilation

"over-breathing" - increased rate and/or depth - CO2 level low

A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client?

1. Notify the rapid response team 2. Reassuring the client and family members (helps stabilize the client) 3. Elevating the head of the bed 4. Preparing for oxygen therapy and blood gas analysis 5. Monitoring and assessing for other changes

NormalRBC Count

4.7/6.1 M/ml

Normal WBC Count

4.8-10.8 K/ml

Mean Platelet Volume (MPV)

8.6-11.7 fl mL The average size of platelets in a volume of blood.

Normal Mean Corpuscular Volume (MCV)

81 - 99 fl (femtoliters, a fraction of one millionth of a liter) The average volume of a red blood cell.

A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment?

A client with acute asthma and 85% oxygen saturation

Biot's Respirations

Abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.

Neutropenia

An abnormally low count of a type of white blood cell

Hypoventilation

An abnormally low respiratory rate and the depth of ventilation is depressed.

Which complications does the nurse anticipate in the client who has blue-colored nail beds?

Cardiopulmonary Disease

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply.

Checking the tubes for kinks Posting "no smoking" signs in the client's room

For which illness should airborne precautions be implemented?

Chickenpox

Asthma

reduced diameter of airways, bronchospasm. *Use of albuterol (Beta-2 Adrenergic Receptor agonist - triggers a response) = bronchodilator). Affects Beta-1 Adrenergic Receptors in the heart also - increase pulse, BP. Wouldn't give a Beta-1 Blocker (for example hypertension) to someone who needs a Beta-2 agonist. The blocking of Beta-1 would also block some of the Beta-2 agonist effect.

Normal Red Cell Distribution Width (RDW)

11% - 15% A measurement of the variability of red cell size and shape.

Normal Mean Corpuscular Hemoglobin (MCH)

27 - 34 PG (pictograms, one trillionth of a gram) The average amount of hemoglobin in the average red cell.

What should be the priority action of the nurse who is caring for a client with a leg in traction(broken leg)?

Assessing the skin integrity should come before assessing the broken bone or assessing for mobility because skin breakdown can occur quickly

The primary healthcare provider prescribes thioridazine and assigns the nurse to assess the client for orthostatic hypotension. Which interventions would the nurse perform? Select all that apply.

Measuring BP before dosing Measuring BP 1 hr after dosing Measuring BP 1 or 2 mins after clients stands or sits *Antipsychotic drugs such as thioridazine may cause orthostatic hypotension as a side effect. Before delivering a dose, the nurse should measure the client's blood pressure.

Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply.

Midline Trachea Pink Nasal Mucosa Nonlabored Respirations @ 14breaths/min

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply.

Minimizing medications Modifying the home environment Manage foot & footwear problems

Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth?

Auscultation

The nurse is teaching a group of student nurses about caring for a hospitalized immunosuppressed client. Which statement(s) made by the student nurse indicates the need for further teaching? Select all that apply.

"I should inspect the client's mouth at least every 4 hours."--should be every 8 not every 4 "I should monitor the vital signs of the client every 8 hours."--should be every 4 hrs not every 8 "I should ensure that that the client's room and bathroom are cleaned at least once a week."--should be cleaned at least once daily

Chronic Bronchitis

- inflammation of the lining of the bronchial tubes (cough/sputum)

Pectus excavatum

A condition in which the breastbone sinks into the chest.

Sustained Fever Pattern

A constant body temperature continuously above 38° C (100.4° F) with little fluctuation

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

A list of facts related to the incident as witnessed by the nurse. **In an incident report, fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.

Post-Op Atelectasis:

After surgery, it may be painful to breathe, patients don't move around as much as usual, so mucus clogs small airways, alveoli unable to open ("collapse"). To decrease risk of atelectasis - patient uses incentive spirometer. Have patient sit upright, seal lips around mouthpiece - breath in slowly and deeply (piston raises) & hold breath as long as possible (maintains a sustained inspiration, opens airways).

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first?

Assess the patency of airway.

The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority?

Assessing airway patency

The nurse decides to teach deep-breathing exercises to a client recovering from a surgery. Which professional responsibility does the nurse display?

Autonomy

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply.

Bounding pulse Presence of dependent edema Neck vein distention in the upright position

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply.

Checking the child's weight every day Calculating the dose as carefully as possible Assessing the child regularly to prevent electrolyte loss

Cheyne-Stokes Respiration

Cheyne-Stokes respiration is also known as periodic respiration, with cycles of respiration that are increasingly deeper then shallower with possible periods of apnoea.

A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time?

Client with epilepsy - epilepsy does not cause circulatory inaccuracy

What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath?

Clubbing

Atelectasis

Complete or partial collapse of a lung or a section (lobe) of a lung.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?

Elevate the head of the client's bed and obtain vital signs.

What is considered to be the highest priority for an assault victim who presents to the emergency department?

Ensuring the client's emotional and physical safety

Which are extrinsic factors responsible for falls in older adults? Select all that apply.

Environmental factors Inappropriate footwear Improper use of assistive devices

Which first line medication would the nurse state is used to treat anaphylactic reactions?

Epinephrine

Intermittent Fever Pattern

Fever spikes are interspersed with normal temperature levels.

Candidiasis

Fungal infection

The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction?

Inhaling air fully before inserting the mouth piece

Cardiopulmonary resuscitation

Initiated in a client w/ no pulse

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?

Kussmaul's respiration

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply.

Lips Mouth Nail Beds

Low Pitched Crackles

May be present in pt w/ pneumonia

Which diseases can be transmitted from client to client by droplet infection? Select all that apply.

Measles Pertussis Diphtheria

The nurse is caring for clients in the pulmonary unit and suspects that one has tuberculosis. What is the priority nursing intervention in this situation?

Move the client to an airborne isolation room

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply.

Obtain blood cultures immediately Administer antibiotic sTAT as prescribed --Monitor for pruritis and rashes & teach the client hygiene AFTER they have been stabilized; not a priority

Needle thoracostomy

Performed in a client w/ absent breathing sounds

Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury?

Performing Jaw Thrust Maneuver

Relapsing Fever Pattern

Periods of febrile episodes coupled with periods of acceptable temperature values

What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply.

Pruritis Wheezing Bronchospasm

A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription?

Recognizing that PRN prescriptions are unacceptable for restraints

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first?

Respirations

Apnea

Respirations cease for several seconds

The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client?

Shaving with a straight blade razor.

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions?

Sputum is free of acid fast bacteria

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation?

Stop administering the medication

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?

Stop the blood transfusion immediately

An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation?

Teach the client coughing and deep breathing exercises

What is the normal RBC count for a healthy male?

The normal RBC count for a healthy male is 4.7 to 6.1 million/mm3

An elderly adult with Parkinson's disease falls while going to the bathroom and gets injured. The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system?

The nurse should document the incident in the occurrence report tool.

Tachypnea

The rate of breathing is regular, but abnormally rapid

Jaw Thrust Maneuver

The recommended procedure for opening the airway of an unconscious client with a possible spinal or neck injury.

Hyperpnea

The respirations are labored, the depth is increased, and the rate is increased.

What is minimum urinary output nurses should watch for?

The urine output should be at least 30 ml per hour. Less than 30 ml per hour indicates the need for notifying the healthcare provider because low urine output indicates volume depletion that may result in renal damage.

What assessment findings indicate that an older client is at risk for developing an infection? Select all that apply.

Thin skin Weak Cough Sluggish bowl sounds Indwelling urinary catheter

Furosemide

Treats fluid retention (edema) and high blood pressure. This medicine is a diuretic (water pill). Can take with food if med upsets client's stomach. This medicine may cause the following problems: --Low levels of minerals in your blood, such as potassium and sodium --Blood sugar level changes --Hearing problems

What is the earliest sign of tissue deoxygenation?

Unexplained restlessness

The registered nurse finds that a client cared for by a student nurse has developed an infection. Which action of the student nurse does the registered nurse suspect to be the cause of infection?

Use of a wet dressing

Incentive Spirometry

Used to improve inspiratory muscle action and to prevent or reverse atelectasis in a client with pneumonia. The client is instructed to exhale fully and then insert the mouthpiece. Inhaling the air before inserting the mouthpiece may cause harm to the client and therefore needs correction. After the process is completed, the volume of air inspired is recorded. A client with pneumonia is instructed to perform 10 breaths per session every hour while awake. Taking a long, slow, deep breath keeping the mouthpiece in place helps to improve inspiratory muscle action.

Verucca vulgaris

Viral

After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion?

Wheezing

Methemoglobinemia

a complication in which the mucous membranes appear blue in color due to increased deoxygenated blood in the body.

Pectus carinatum

also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs.

. Emphysema

alveoli are destroyed as a result of damaging exposure - scar tissue replaces stretchy elastin fibers, lose elastic recoil, lungs inflate, but don't deflate: barrel chest. Airways can also be obstructed (mucus).

Normal Hemoglobin Count

amount of hemoglobin in a volume of blood (how much is available for oxygen to latch onto). Male: 14.0 - 17.5 g/dL, Female: 12.3 - 15.3 g/dL

Rhonchi

associated with obstruction by a foreign body.

Bradypnea

breathing rate is regular, but it is abnormally slow

Venturi Mask

can adjust oxygen amount with much more precision - for patients with chronic lung disease.

Pleural Friction Rub

can be heard in cases of pleurisy.

Polycythemia vera

characterized by brown spots on the skin caused by increased melanin production.

Hypoventilation

decreased rate and/or depth - low oxygen level, high carbon dioxide level. 1. Bradypnea - too slow < 10 breaths/minute 2. Hypopnea - too shallow *If caused by opioids, can be reversed with Narcan

Orthopnea

difficulty breathing when supine (lying flat).

Remittent Fever Pattern

fever spikes and falls without returning to normal temperature levels

Kussmaul breathing

is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.