Nursing Fundamentals ATI
What is the normal magnesium level range?
1.3 - 2.1 mEq/L
What is the normal BUN range?
10-20 mg/dL
What is a normal calcium level?
8.4-10.2mg/dL
What is the appropriate mmHG amount of suction used for a single lumen NG tube?
80-100mmHg Higher suction can traumatize the gastric lining
Where is the posterior tibial pulse?
Located on inner side of the ankle
What is the goal of the introductory/orientation phase?
The nurse should asses the clients level of comfort and establish a rapport during this phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation.
How long and how much oxygen percentage should be used to hyperventilate a patient with a tracheostomy during suctioning?
The nurse should hyperventilate the client with 100% oxygen for at least 2 minutes before suctioning to decrease hypoxia
What is the maximum amount of passes that should be performed during a tracheostomy suctioning?
The nurse should perform a maximum of 3 passes with the suction catheter because suctioning can cause hypoxia and induce dysrhythmia.
For a child younger than 3 years of age, what steps should be taken to administer otic solutions into the ear?
The nurse should straighten the ear canal by pulling the auricle down and back prior to administering otic medication
What is a indirect Coombs test used for?
This test determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal clients sensitization and if there is RH incompatibility.
What is another name for parvovirus B19, and what does it affect? Is it transmissible from a pregnant woman to her baby?
This virus spreads through respiratory secretions such as saliva, sputum, or nasal mucus when an infected person coughs or sneezes. Another name for this virus is fifths disease. The virus can also spread through blood or blood products therefore a pregnant woman who is infected with the virus can pass the virus to her baby. There are currently no vaccinations to protect against fifth disease.
What is the goal of the working phase of a client interview?
To gather client health history, including previous and recent illnesses, sociocultural history, and previous or recent surgeries.
When does treatment begin for pregnant women with HIV? And what type of treatment is used?
Treatment for HIV will be during the prenatal and perinatal periods. Treatment with anti-retroviral prophylaxis such as Zidovudine, triple drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease transmission of HIV to the newborn.
What is a cholecystectomy?
surgical removal of the gallbladder
What is primary prevention?
Examples include influenza immunizations, education of clients, etc
What is kyphosis?
Humpback in the thoracic area, aka hunchback
What is tertiary prevention?
Rehabilitative therapies and monitoring of health to prevent complications or further illness, injury, or disability
What does the abbreviation PC stand for?
after meals
What is the normal creatinine range?
0.5-1.1 mg/dL for women 0.6-1.3 mg/dL for men
What is the normal urine specific gravity range?
1.010-1.025
What is the normal sodium level range?
135-145 mEq/L
What is a normal potassium range?
3.5-5.0 mEq/L
What is the normal potassium level range?
3.5-5.0 mEq/L
How long should a patient stay in a side lying position after insertion of misoprostol?
30-40 minutes after insertion
What bed angle range is appropriate for enteral feedings by NG tube for clients?
30-45° angles before/during feedings
How long (amount of time) should a nurse allow between suctioning passes of a patient with a tracheostomy?
A nurse should allow at least 1 minute between suctioning passes to prevent hypoxia and to hyperventilate the client.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A) "I can administer oxytocin 4 hours after the insertion of the medication" B) "you will need a full bladder prior to insertion of the medication C) "remain in a side lying position for 15 minutes after the medication is inserted" D) "an antacid will be given 20 minutes prior to the insertion of the medication
A) "I can administer oxytocin 4 hours after the insertion of the medication" The nurse can administer oxytocin no sooner than four hours after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.
A nurse is performing a focused assessment of a clients peripheral vascular system. In which of the following locations should the nurse palate the posterior tibial pulse? A) below the medial malleolus B) in the popliteal fossa C) in the antecubital space D) on the dorsum of the foot
A) below the medial malleolus
A nurse is teaching a client how to perform range of motion exercises of the wrist. The perform adduction, which of the following instructions should the nurse include? A) with your palm facing down, move your wrist sideways toward your thumb B) move your palm toward the inner part of your forearm C) with your palm facing down, move your wrist sideways toward your little finger D) bring the back of your hand as far back toward the wrist as you can
A) with your palm facing down, move your wrist sideways toward your thumb
What are Montgomery straps?
Adhesive strips applied to the skin on either side of the surgical wound that have holes for using gauze to tie the dressing securely. When dressing is changed the ties are changed out without changing strips.
What does serous exudate look like and mean?
Appears watery and clear to light yellow in color, indicates plasma from the blood
A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A) retinopathy B) glaucoma C) cataracts D) macular degeneration
B) glaucoma
What is the Kleihauer-Betke test?
Blood test used to detect the amount of fetal blood (hemoglobin) transferred from a fetus to a mothers bloodstream
A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A) people who practice the Islamic faith pray over the deceased for a period of five days before burial B) people who practice the Hindu faith bury the deceased with their head facing north C) people who practice Judaism stay with the body of the deceased until burial D) People who are practicing the Buddhist faith have the female family members prepare the body following death
C) people who practice Judaism stay with the body of the deceased until burial
A nurse is assessing a clients peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A) peripheral pulses equal bilaterally at a rate of 60/min B) radial, brachial, and pedal pulses bilaterally weak C) peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities D) brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable
C) peripheral pulses bilaterally symmetric, equal, and strong is all 4 extremities Documentation of peripheral pulses evaluation's should include the strength of pulsations as well as their quality and symmetry in all four extremities
A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the clients urine is 1.035. Which of the following actions should the nurse take? A) deliver the formula at a slower rate B) request a lower fat formula C) provide more water with feedings D) Instill a lactose free formula
C) provide more water with feedings The elevation in the clients specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to feedings or by instilling water between feedings.
A nurse inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A) remove the NG tube B) advance the NG tube quickly C) pull the NG tube back slightly D) ask the client to tilt his head backward
C) pull the NG tube back slightly And encourage client to breathe the slowly before advancing and having client swallow to assist
A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a clients laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "I will use a stapler remover and remove each suture individually" B) "bandage scissors are used to cut the sutures" C) "tweezers are necessary only for removing retention sutures" D) "I will clip each suture close to the skin and pull it though from the other side"
D) "I will clip each suture close to the skin and pull it through from the other side" Does not disrupt the wound healing process
A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A) liver size B) pedal edema C) skin texture D) gait
D) gait All other answers require palpation
A nurse is preparing to administer a intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A) Vastus Lateralis B) dorsogluteal C) deltoid D) ventrogluteal
D) ventrogluteal This is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels
A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A) middle adulthood B) adolescence C) childhood D) young adulthood
D) young adulthood
Major adverse affect of combined oral contraceptives?
Depression. Other common adverse affects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.
What nutrient is the body typically depleted of in a client with spoon-shaped nails?
Iron
What medication would be given IM for a client who has syphillis and is pregnant?
Penicillin G
What is the Norton scale used for?
Pressure ulcer risk assessment
Which nutritional supplement is primarily responsible for regulating fluid balance?
Protein
Which nutritional supplement plays a large role in tissue repair?
Protein
What is secondary prevention?
Screening! Focuses on identifying the disease early, when it is asymptomatic or mild and implementing measures that can halt of slow disease progression
What is lordosis?
Swayback in the lumbar region (Lumbar, Lordosis) (butt sticks out)
What is Chvostek's sign? And how is it done?
Tap on the pt's face at a point just anterior to the ear and just below the zygomatic bone. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggestive of neuromuscular hyperexcitability caused by hypocalcemia
What is the Romberg test?
Tests the client's equilibrium, client stands with feet together and arms at sides eyes open and then closed. With eyes open and then closed Client should be able to maintain the position for 20 secs with minimal or no swaying
What is kinesthesia?
The ability to sense the position and movement of body parts without visualizing them
What is a main purpose of the medulla and pons of the brainstem?
The brainstem serves as the respiratory control center. If a neurological injury were to occur in this area is could inhibit respiratory effort.
What is the maximum time a nurse should apply suctioning when suctioning a patient with a tracheostomy?
The nurse should apply suction for no more than 10 seconds
What is the Braden Scale used for?
Used to predict risk of patient getting a pressure ulcer. Range of score is from 6-23, but if score is less than 18 the patient is at risk for a pressure ulcer.
What is the Rinne test?
Vibrating tuning fork held from ear and then placed on mastoid. In conduction hearing loss they have bone conduction but not air conduction.
Should you warm up enteral feeding formulas to room temperature before giving to client? Why?
YES! This can help reduce abdominal cramping and discomfort from cold formula ingestion.
Where is the popliteal pulse located?
behind the knee
Signs and symptoms of hyperglycemia
polyuria, polydipsia, polyphagia, nausea/vomiting, abdominal pain, constipation, drowsiness, headaches, flushed/dry skin, fruity breath odor, weak rapid pulse, urine positive for glucose and acetone, blood glucose above 200
signs and symptoms of hypoglycemia
reduced cognition, tremors, diaphoresis, weakness, hunger, headache, irritability, seizure, clammy skin, blurred/double vision, shallowed respirations
What does the acronym RACE stand for?
rescue, alarm, contain, extinguish In regards to fires in a health care facility
What is proprioception?
sense of body position and movement, The awareness of the position of the body
A Middle Aged adult client is discussing future plans with the nurse. Which of the following statement should the nurse identify as an indication that the client is having difficulty achieving Eriksons developmental task for this age group? A) "we miss our daughter so much that we are going to move closer to her" B) "I think this year I can plan on managing the funding at church" C) "I really wish I could lose some of this weight" D) "I find I am spending more time at work now that my son is at college"
A) "we miss our daughter so much that we are going to move closer to her"
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. So which of the following complication should the nurse assess? A) abruptio placenta B) placenta previa C) preeclampsia D) maternal bradycardia
A) abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta
A nurse is performing a neurological assessment for a client. By asking the client to stick his tongue out, which of the following cranial nerves is the nurse testing? A) cranial nerve XII B) cranial nerve X C) cranial nerve VIII D) cranial nerve V
A) cranial nerve XII (hypoglossal)
A nurse is teaching range of motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? A) The client holds the hand with the palm up B) The client holds the hand with the palm down C) The client points the fingers toward the floor D) The client points the fingers toward the ceiling
A) the client holds the hand with the palm up
A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? A) use the pain scale to determine clients pain level B) discuss the adverse affects of pain medication with the client C) obtain the clients vital signs D) check the clients allergies
A) use the pain scale to determine clients pain level
A nurse is caring for a middle aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Eriksons developmental task for her age group? A) "I am comfortable with my decision to choose a lifelong partner" B) "I think I have done a good job with my children since they are all independent now" C) "As I look back over my life, I can see that I have achieved most of the goals I set for myself" D) "I love my work so much that it is difficult to think about retirement"
B) "I think I have done a good job with my children since they are all independent now"
A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the clients body? A) heart B) lungs C) thyroid gland D) skin
B) lungs Creates vibration that helps examiner determine density of the underlying tissue.
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A) lower medial quadrant of the buttock near the coccyx B) side hip between the iliac crest and anterior iliac spine C) tissue of the posterior upper arm D) lower inner thigh 4 finger widths above the patella
B) side hip between the iliac crest and anterior iliac spine
A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A) calcium 9.5 mg/dL B) sodium 150 mEq/L C) potassium 4 mEq/L D) magnesium 1.5 mEq/L
B) sodium 150 mEq/L
A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply) A) allowing the client to speak B) stabilizing the position of the tube C) preventing aspiration of secretions D) preventing air leaks E) preventing tracheal injury
B) stabilizing the position of the tube C) preventing aspiration of secretions D) preventing air leaks
What does sanguineous drainage look like and mean?
Bright red is color, indicates accumulation of RBCs from the plasma
A nurse in a long term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A) "a lot of clients who are cared for at home have the same problem" B) "don't worry about it. He will get a bath, and that will take care of the odor" C) "it must be difficult to care for someone who is confined to bed" D) "when was the last time that he had a bath?"
C) "it must be difficult to care for someone who is confined to bed"
A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A) muscle tremors B) positive chvosteks sign C) depressed deep tendon reflexes D) numbness around the mouth
C) depressed deep tendon reflexes
A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps. A) place a name tag on the body B) wash the clients body C) obtain the pronouncement of death from the provider D) ask the clients family members if they would like to view the body E) remove tubes and indwelling lines
C) obtain the pronouncement of death from the provider E) remove tubes and indwelling lines B) wash the clients body D) ask the clients family members if they would like to view the body E) place a name tag on the body
A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A) carminative B) hypertonic C) oil retention D) sodium polystyrene sulfate
C) oil retention Carminative is for relief of flatus, hypertonic is used to cleanse the clients bowels (surgery prep), and sodium polystyrene sulfate is used for a client who has a high potassium level
A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A) sims B) supine C) sitting D) standing
C) sitting The costovertebral angle is the area where the spine and the Twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion of that region
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A) perform tracheostomy care using medical asepsis B) allow enough slack under the tracheostomy ties to insert three fingers C) soak the inner cannula of the tracheostomy tube in normal saline D) to a sterile gauze pad to place between the neck and the tracheostomy tube
C) soak the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions.
A nurse is teaching a client who has urinary incontinence about bladder retaining. Which of the following instructions should the nurse include? A) wake up every 2 hours to urinate during the night B) drink citrus juices throughout the day C) try to block the urge to urinate until the next scheduled time D) limit fluids to no more than 1L (34oz) during waking hours
C) try to block the urge to urinate until the next scheduled time If client feels need to urinate before next scheduled time, they should try slow, deep breaths to help reduce the urge. They can also try 5 or 6 strong and quick pelvic muscle exercises
A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A) don sterile gloves B) use the dominant hand to retract the labia C) use the index finger to insert the suppository D) ease the suppository along the anterior vaginal wall
C) use the index finger to insert the suppository
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A) numbness of the extremities B) bradycardia C) positive chvosteks sign D) Abdominal cramping
D) abdominal cramping This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery. Which of the following responses should the nurse provide? A) "it's for your safety. Dentures can slip and block your airway during surgery" B) "you wouldn't want your teeth to be lost of broken during surgery, would you?" C) "the anesthesiologist requires all clients to remove their dentures" D) "what worries you about being without your teeth?"
D) "what worries you about being without your teeth?"
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include? A) serve foods at warm or hot temperatures B) offer the client low density foods C) make sure the client lies supine after meals D) Limit drinking liquids with food
D) Limit drinking liquids with food
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A) fifth intercostal space just medial to the midclavicular line B) Second intercostal space to the left of the sternum C) fifth intercostal space to the left of the sternum D) Second intercostal space to the right of the sternum
D) Second intercostal space to the right of the sternum
A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A) trauma B) severe infection C) iron deficiency anemia D) chronic hypoxemia
D) chronic hypoxemia
A nurse is changing the dressings for a client who is 3 days post operative following a cholecystectomy. The nurse observes yellow thick drainage on the dressing. The nurse should document this finding at which of the following types of drainage? A) sanguineous exudate B) serous exudate C) serosanguineous exudate D) purulent exudate
D) purulent exudate Purulent exudate is yellow, green, or brown, and usually indicates would sloughing or infection
What is Costovertebral angle tenderness?
Pain that results from touching the region inside the costovertebral angle. The CVA is formed by the 12th rib and the spine. (May indicate kidney stones or pyelonenephritis)
What is gustation?
The ability to taste
What is primary intention wound healing?
when the edges of a clean wound are closed in some manner immediately (i.e. suture, steri strips, staples) and edges become well approximated during healing
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply) A) gingivitis B) dry, brittle hair C) edema D) spoon-shaped nails E) poor wound healing
B- dry, brittle hair C- edema E- poor wound healing
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A) advocacy ensures client safety, health, and rights B) advocacy ensures the nurses are able to explain their own actions C) advocacy ensures that nurses follow through on their promise to clients D) Advocacy ensures fairness in client care delivery and use of resources
A) Advocacy ensures client safety, health, and rights
A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A) Air conduction is less than bone conduction in the left ear B) Air conduction is greater than bone conduction in the left ear C) sound is lateralizing to the right ear D) Sound is lateralizing to the left ear
A) Air conduction is less than bone conduction in the left ear
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect a provider to prescribe? A) kleihaur-Betke test B) progesterone serum level C) lecithin/sphingomyelin (L/S) ratio D) maternal alpha-fetoprotein (AFP)
A) Kleihaur-Betke test The nurse should expect the provider to prescribe a kleihauer-betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if RHo- (D) immune globulin therapy should be administered to a client who is rh-negative.
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A) Press gently on the tragus of the clients ear B) Pack a small piece of cotton deep into the clients ear canal C) Move the clients auricle down and back toward her head D) tilt the clients head backward for five minutes
A) Press gently on the tragus of the clients ear
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A) ask another nurse to observe the medication wastage B) notify the pharmacy when wasting the medication C) Lock the remaining medication in the controlled substance cabinet D) dispose of the vial with the remaining medication in a sharps container
A) ask another nurse to observe the medication wastage
A nurse is preparing to enter an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (select all that apply) A) coat the tip of the tube with a water soluble lubricant B) Ask the client to swallow water while the tube enters her throat C) placed a coiled tube in ice chips prior to insertion D) Tell the client to tilt her head backward as insertion begins E) instruct the client to bear down during insertion
A) coat the tip of the tube with a water soluble lubricant B) ask the client to swallow water while the tube enters her throat D) tell the client to tilt her head backwards as insertion begins
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A) evaluate pedal pulses B) obtain a medical history C) measure vital signs D) assess for leg pain
A) evaluate pedal pulses For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. Following ABC's (C-circulation)
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? A) examine personal values about the issue B) tell the parents that it is a necessary procedure C) inform the parents that the staff does not require their consent D) Contact a spiritual support person to explain the importance of the procedure
A) examine personal values about the issue
A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A) fats provide energy B) carbohydrates repair body tissue C) fats regulate fluid balance D) carbohydrates prevent interstitial edema
A) fats provide energy Fats serve as a stored energy sprite for the body, providing 9 cal/g of energy
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A) hold the dropper 1cm (0.5in) above the ear canal during administration B) apply pressure to the nasolacrimal duct following administration C) place a cotton ball into the ear canal for 30 minutes following administration D) straighten the ear canal by pulling the auricle down and back prior to administration
A) hold the dropper 1cm (0.5in) above the ear canal during administration
A nurse is preparing to administer a liquid medication from a bottle to a client. Which of the following actions should the nurse take? A) hold the medication bottle with the label against the palm of the hand when pouring B) place the cap with the inside facing down on a hard surface C) fill the cup until the medication is even with the edge of the dosage scale D) pour any excess liquid back into the bottle after measuring
A) hold the medication bottle with the label against the palm of the hand when pouring The nurse should take this action to protect the label of the medication from any wet contents to avoid the label to fade or become ineligible.
A nurse on a mental health unit is preparing to terminate the nurse client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A) loss B) trust C) self disclosure D) risk-taking
A) loss Even when planned, the close of a relationship between a nurse and client is expected to have a feeling of loss.
A nurse in a providers office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A) osteoporosis B) scoliosis C) kyphosis D) lordosis
A) osteoporosis This occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse causing a loss in height
A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A) Pad the clients wrist before applying the restraints B) evaluate the clients circulation every 8hr after application C) remove the restraints every 4hr to evaluate clients status D) secure the restraint ties to the beds side rails
A) pad the clients wrist before applying the restraints
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A) place the client in a lateral position with the head turned to the side before beginning the procedure B) use the thumb and index finger to keep the clients mouth open C) rinse the clients mouth with an alcohol-based mouthwash following the procedure D) cleanse the clients mucous membranes with lemon glycerin sponges
A) place the client in a lateral position with the head turned to the side before beginning the procedure
A nurse is preparing to provide chest physiotherapy for a client who had left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A) place the client in the trendelenburg position B) perform percussions directly over the clients bare skin C) use a flattened hand to perform percussions D) remind the client that check percussions can cause mild pain
A) place the client in trendelenburg position The nurse should place the client in right sided trendelenburg position to promote drainage from the clients left lower lobe (The nurse should use a cupped hand to perform percussions)
A nurse is performing a suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A) pull suction catheter back 1cm (0.5in) if the client starts coughing B) allow 30 second intervals between suctioning passes C) hyperventilate the client with 50% oxygen for 30 seconds D) perform a maximum of 4 passes with suction catheter
A) pull suction catheter back 1cm (0.5in) of the client starts coughing
A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? A) regulation of acid-base balance B) reabsorption of nutrients for cellular growth C) regulation of body temperature D) secretion of hormones needed for growth
A) regulation of acid-base balance
A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? A) remove the sleeve of the down from the arm without the IV line B) slow the infusion rate using the roller clamp C) disconnect the IV line from the pump D) Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown
A) remove the sleeve of the gown from the arm without the IV line
A nurse is assessing a clients incision and observes the drainage to be blood tinged. Which of the following terms should the nurse use to document this finding? A) sanguineous B) purulent C) serous D) hyperemia
A) sanguineous
A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A) scoliosis B) lordosis C) torticollis D) kyphosis
A) scoliosis
A nurse on a medical surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the clients bedside at all times? A) suction equipment B) clean gloves C) Blankets D) oxygen
A) suction equipment Greatest risk to a seizure client is aspiration of secretions or Emesis
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which is the following vitamins and minerals should the nurse plan to increase in the clients diet? A) vitamin C and zinc B) vitamin D C) vitamin K and iron D) Calcium
A) vitamin C and zinc The body needs both of these to fight a wound infection
A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A) whole milk B) chicken C) oranges D) dried peas
A) whole milk
What does serosanguineous exudate look like and mean?
Appears pale yellow to blood-tinged, watery drainage may also be evident. Indicates plasma mixed with light bloody drainage
How many ml should a nurse use to flush enteral feeding tubes following a feeding?
At least 30ml of water after feeding to maintain patency of the feeding tube
What medications (class) should you avoid giving with misoprostol?
Avoid administering aluminum hydroxide and magnesium containing antacids with misoprostol
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states " clear liquids, advance diet as tolerated." Which of the following responses should the nurse make? A) " lunch trays should be here within the hour" B) " I am going to listen to your abdomen" C) " i'll get you some water to drink" D) " let's wait a bit so you don't feel sick"
B) " I am going to listen to your abdomen"
A nurse is instructing a client about collecting a 24 hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A) "the next time I urinate will be the first specimen of the collection" B) "I'll make sure to keep the collection bottle in the container of ice they gave me" C) "once the container is half full, I no longer have to add any more urine" D) "it's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test"
B) "I'll make sure to keep the collection bottle in the container of ice they gave me" The urine collection must remain chilled to prevent any change in urine composition during the collection
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A) make sure the clients room has at least six air exchanges per hour B) make sure the client wears a mask went outside her room if there is construction in the area C) place the client in a private room with negative pressure airflow D) Wear an N95 respirator when giving the client direct care
B) Make sure the client wears a mask went outside her room if there is construction in the area
A nurse is changing the dressings for a client who has 2 penrose drains near an abdominal incision. Which of the following adhering devices is the best for the nurse to use to decrease skin irritation? A) abdominal binder B) Montgomery straps C) hypoallergenic tape D) plastic tape
B) Montgomery straps
A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A) a client who's 1 day postoperative following a lobectomy for small cell carcinoma and has a chest tube with 35ml/hr of bright red, bloody drainage B) a client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C) a client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20ml/hr of serosanguinous drainage D) a client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300ml/hr of reddish pink urine
B) a client who is 2 days postoperative following a colectomy due to colorectal cancer and has a ostomy bag full of bright red, bloody drainage An ostomy bag full of blood indicates that the clients bowel is hemorrhaging
A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A) antigravity B) antagonistic C) synergistic D) skeletal
B) antagonistic The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A) insert the suction catheter while the client is swallowing B) apply intermittent suction when withdrawing the catheter C) place the catheter in a location that is clean and dry for later use D) All the suction catheter with her clean, non-dominant hand
B) apply intermittent suction when withdrawing the catheter The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa, however, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise
A nurse is assessing a clients vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? A) palpation of both carotid arteries simultaneously B) auscultation of the arteries for bruits with the bell of the stethoscope C) palpation of the arteries for murmurs bilaterally D) auscultation of the arteries for thrills with the diaphragm of the stethoscope
B) auscultation of the arteries for bruits with the bell of the stethoscope
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A) blow into the spirometer to elevate the balls in the device B) cough deeply after each use C) clean the spirometer with an alcohol swab after each use D) use the spirometer ever 8 hours
B) cough deeply after each use The client should call deeply to facilitate the removal of secretions from lungs. This incentive spirometer is used with inhalation.
A nurse is performing otoscopic examination of a clients right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A) obtain and audiology referral B) document this as an expected finding C) irrigate the ear with warm water D) document mild inflammation
B) document this as an expected finding The light of the otoscope reflects off the tympanic membrane, which is cone shaped or triangular. In the right ear it is visible in the right lower quadrant of the eardrum. In the left ear it is visible in the left lower quadrant.
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A) redness at the Infusion site B) edema at the infusion site C) warmth at the infusion site D) oozing of blood at the infusion site
B) edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration.
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration? A) irrigate the tubing with 30ml of sterile water B) Elevate the head of the bed to 30-45° C) suggest changing the feeding to lactose free formula D) warm the enteral formula to room temperature before feeding
B) elevate head of bed to 30-45°
A nurse is assessing for adult clients. Which of the following physical assessment techniques should the nurse use? A) use the face, legs, activity, cry, and consolability (FLACC) pain rating scale for a client who is experiencing pain B) ensure the bladder of the blood pressure cuffs around 80% of the clients arm C) obtain an apical heart rate by auscultating at the third intercostal space left of the sternum D) palpate the clients abdomen before auscultating bowel sounds
B) ensure the bladder of the blood pressure cuffs around 80% of the clients arm
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? A) exhale slowly to reach the goal volume B) hold the breath for 5 sec after goal volume is reached C) continue to breath deeply between each cycle D) limit the repeat pattern of breathing to 5 breaths
B) hold the breath for 5 sec after goal volume is reached This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia.
A nurse is caring for a client who is scheduled to receive transcutaneous electrical stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make? A) it provides distraction from the pain B) it modulates the transmission of the pain impulse C) it promotes increased circulation to the painful area D) it elicits a relaxation response
B) it modulates the transmission of the pain impulse
A nurse on a medical surgical unit it caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? A) identify goal for client care B) obtain client information C) document nursing care needs D) evaluate the effectiveness of care
B) obtain client information
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A) insert the catheter at a 45° angle B) place the clients arm in a dependent position C) shave excess hair from the insertion site D) Initiate IV therapy in the veins of the hand
B) placed the clients arm in a dependent position The nurse should place the clients arm in a dependent position because the veins will dilate due to gravity
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A) regulate the flow rate by aligning the rate with the top of the ball inside the flow meter B) regulate oxygen via nasal cannula at a flow rate of no more than 6L/MIN C) make sure the reservoir bag of a partial re-breathing mask remains deflated D) Use petroleum jelly to lubricate the clients nares, face, and lips
B) regulate oxygen via nasal cannula at a slow rate of no more than 6L/min Rates above 6 L per minute have a drawing affect and force clients to swallow air excessively without increasing their fraction of inspired oxygen
A nurse is caring for A prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A) administer antiviral medication B) schedule and ultrasound examination C) administer haemophilus influenzae type b vaccine D) schedule an indirect Coombs test
B) schedule and ultrasound examination The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect a possible development of fetal hydrops. Also the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A) holding a community clinic to administer influenza immunizations B) screening groups of older adults in nursing care facilities for early influenza manifestations C) educating parents of young children about the dangers of influenza D) finding rehabilitation programs for older adults who have complications related to influenza
B) screening groups of older adults in nursing care facilities for early influenza manifestations
As part of a neurological examination, A nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A) gustation B) stereognosis C) proprioception D) kinesthesia
B) stereognosis Stereognosis is the ability to identify an objects size, shape, and texture via tactile sensation
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A) continue the teaching, but check afterward with the surgeon about informed consent B) stop the teaching and check with the surgeon about informed consent C) stop the teaching and ask the client to sign an informed consent D) continue the teaching and check the clients medical record afterward for a signed consent form
B) stop the teaching and check with the surgeon about informed consent
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A) the client asks the nurse to repeat the instructions before attempting the exercises B) the client reports severe pain C) the client asks the nurse how often deep breathing should be done after surgery D) the client tells the nurse that this exercise will probably be painful after surgery
B) the client reports severe pain A client who is experiencing severe pain is not able to concentrate and is not ready to learn a new activity
A nurse is caring for a semiconscious patient who had a small bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply) A) auscultate injected air B) verify the initial X-ray examination C) measure the length of the exposed tube D) determine the pH of aspirated fluid E) check the aspirated fluid for glucose
B) verify the initial X-ray examination C) measure the length of the exposed tube D) determine the pH of the aspirated fluid
A nurse is planning care for a client who had a single lumen nasogastric tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A) set the suction machine at 120mmHg B) provide oral hygiene frequently C) measure the amount of drainage from the NG tube every shift D) secure the NG tube to the clients gown E) apply petroleum jelly to the clients nares
B, D, C A. Is incorrect because single lumen NG tubes are used for intermittent suction, and the machine is set at 80-100 mmHg. Higher suction can traumatize the gastric lining. E. Is incorrect because the client could aspirate an oil based lubricant like petroleum jelly into the lungs, which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin
A nurse is talking with the parent of a preschool aged child who tells the nurse "my child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A) "during this phase, feed your child anything that she will eat" B) "increase the amount of calories and water your child consumes" C) "keep a diary of the foods your child eats daily" D) "provide a large variety of fruit juices for your child to choose from"
C) "keep a diary of the foods your child eats daily" Parent should keep a diary for at least one week of their child's food intake, parents are typically surprised how how well their children actually eat.
A nurse is caring for a client who has a terminal illness. The family wants to care for the client home. Which of the following statements indicates that the nurse understands family-centered care? A) "social services can contact various community resources that will be helpful" B) "I will review the care plan to make the necessary changes" C) "let's set up a meeting time with the doctor to discuss your options for home care" D) "I will make a list of things we need to do before discharge"
C) "let's set up a meeting time with the doctor to discuss your options for home care"
A nurse is caring for a client who has a methicillin-resistant staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A) Don a gown before entering the room and remove it before exiting B) wear a mask while in the clients room C) Don gloves when entering the room and use hand sanitizer when exiting D) take no special precautions unless engaging in direct contact with the client
C) Don gloves when entering the room and use hand sanitizer when exiting
A nurse is using an open irrigation technique to irrigate a clients in dwelling catheter. Which of the following actions should the nurse take? A) place the client and a side lying position B) Instill 15 mL of irrigation fluid into the catheter with each flush C) Subtract the amount of irrigant used from the clients urine output D) Perform the irrigation using a 20 mL syringe
C) Subtract the amount of irrigant used from the clients urine output
A home health nurse is performing a follow up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A) The client is receiving formula at room temperature B) The feedings infuse at a slow, continuous trip over eight hours each night C) The clients caregiver washes out the feeding bag with warm water once every 24 hours D) The clients caregiver flushes the tubing with water before and after administering medications
C) The clients caregiver washes out the feeding bag with warm water once every 24 hours Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination.
A nurse is administering an IM injection to a 5-month old infant. Which of the following injection sites should the nurse use? A) Deltoid B) Ventrogluteal C) Vastus Lateralis D) Dorsogluteal
C) Vastus Lateralis The nurse should choose this site over the anterior thigh to for IM injections for infants and children
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A) encourage the child to cough frequently to clear congestion from anesthesia B) place a heating pad on the child's neck for comfort C) administer analgesics to the child on a routine schedule throughout the day and night D) Provide the child with ice cream when oral intake is initiated
C) administer analgesics to the child on a routine schedule throughout the day and night
A nurse is caring for a client who requires ventilatory assistance with breathing following a MVA. The nurse should suspect injury to which of the following parts of the brain, and why? A) hypothalamus B) cerebral cortex C) brainstem D) cerebellum
C) brainstem The nurse should identify an injury to the MEDULLA AND PONS of the brainstem for a client who is experiencing difficulty with breathing. The brainstem serves as the respiratory controls center, and a neurological injury can impair this center and inhibit respiratory effort
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A) verify the clients name on their identification bracelet with the medication administration record B) call the pharmacy to determine whether the clients medications are available C) compare the clients home medications with the providers prescriptions D) place the clients home medication bottles in a secure location
C) compare the clients home medications with the providers prescriptions
A nurse is talking with client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should Identify that the client is in which of the following stages of dying? A) anger B) bargaining C) depression D) acceptance
C) depression During the stage of depression the client has realized the full impact of the loss and might express hopelessness or despair
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A) hold the irrigator 1.25cm (0.5in) above the eye B) direct the irrigation solution up toward the upper eyelid C) exert pressure on the bony prominences when holding the eyelids open D) direct irrigation from the outer canthus to the inner canthus of the eye
C) exert pressure on the bony prominences when holding the eyelids open
A nurse is teaching a middle aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this clients routine health screening? A) annual papanicolaou (Pap) testing B) mammogram every 2 years C) eye examination ever 2 years D) annual colonoscopy
C) eye examination ever 2 years
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A) lubricate up to 3.2cm (1.25in) of the tip of the rectal tube B) position the client on the right side C) insert the tip of the tubing 8cm (3.1in) D) hold the enema container 61cm (24in) above the rectum
C) insert the tip of the tubing 8cm (3.1in)
A nurse in an emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the clients HIV infection status. Which of the following actions should the nurse take? A) inform the gaurd that the warden must request this information B) ask the guard to sign a release of information form C) instruct the guard to ask the inmate D) complete and incident report
C) instruct the guard to ask the Inmate
A nurse is providing teaching to client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A) eggs B) soybeans C) lentils D) yogurt
C) lentils Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds.
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long term care facility. Using this scale, which of the following parameters should the nurse evaluate? A) incontinence B) mental state C) nutrition D) general physical condition
C) nutrition Nutrition, sensory perception, moisture, activity, mobility, and friction and sheer are the parameters on the Braden scale for determining a clients risk of developing pressure ulcers. All other answers refer to the Norton scale.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A) the wound edges are well-approximated B) the wound is closed at a later date C) a skin graft is placed over the wound bed D) granulation tissue fills the wound during healing
D) granulation tissue fills the wound during healing The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A) biofeedback B) aloe C) feverfew D) Acupuncture
D) acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skins surface could increase the risk of further infection.
A nurse in the ED is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A) instill proparacaine hydrochloride eye drops B) perform ocular irrigation of the right eye C) place the client in a supine position with the head turned toward the affected side D) ask the client about first aid performed at the scene
D) ask client about the first aid performed at the scene
A nurse in an urgent care center is caring for a 15 year old client whose symptoms suggest a sexually transmitted infection (STI). The clients parent is unavailable, but the clients grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A) explain that the treatment can wait until the parent is available B) inform the grandmother that she may give consent for treatment C) invoke the principle of implied consent and prepare the client for treatment D) ask the adolescent to sign the consent form
D) ask the adolescent to sign the consent form Unemancipated minors can legally give informed consent for diagnostic procedures and treatment in some situations such as treatments for STI's or substance use disorders
A nurse is caring for a Middle Aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? A) managing a home B) establishing a sense of self in the adult world C) forming new friendships D) ceasing to compare personal indenting with others
D) ceasing to compare personal identity with others Every other option pertains to tasks of a young adult.
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A) withdrawl the specimen from the drainage bag B) cleanse the collection port with soap and water C) place the specimen and a clean specimen cup D) clamp the tubing below the collection port
D) clamp the tubing below the collection port The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup
A nurse is performing a mental status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give a client when evaluating the clients ability to think abstractly? A) subtract by seven serially, starting at 100 B) describe a previous illness C) explain what to do if a fire happened in this room D) Discuss the meaning of a common proverb
D) discuss the meaning of a common proverb
A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? A) close the fire doors on the unit B) use a fire extinguisher on the fire C) pull the nearest fire alarm D) evacuate clients from the hnit
D) evacuate clients from the unit CLIENT SAFETY COMES FIRST FOLLOW "R.A.C.E." Rescue, activate, confine, extinguish
A nurse in the ED is assessing a client who has deep, rapid respiration's. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO- 18. Which of the following acid based imbalances should the nurse identify and report to the provider? A) respiratory alkalosis B) metabolic alkalosis C) respiratory acidosis D) metabolic acidosis
D) metabolic acidosis A pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCO2 values will deviate in opposite directions. Since the PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies a surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and report back in one hour. Which of the following actions should the nurse take next? A) document the provider statement in the medical record B) complete an incident report C) consult the facilities risk manager D) Notify the nursing manager
D) notify the nursing manager
A nurse in a long term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A) assist the client to the floor B) perform an abdominal thrust C) open the airway with a head-chin tilt D) observe the client closely
D) observe the client closely The nurse should observe the client closely at this point in time. As long as the client is able to cough strongly, the nurse does not need to intervene.
A nurse is obtaining the blood pressure in a clients lower extremity. Which of the following actions should the nurse take? A) auscultate the blood pressure at the dorsalis pedis artery B) measure the blood pressure with the client sitting on the side of the bed C) place the cuff 7.6cm (3in) above the popliteal artery D) place the bladder of the cuff over the posterior aspect of the thigh
D) place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the bladder of the cuff when a nurse is measuring a lower extremity blood pressure
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? A) administer penicillin G 2.4 million units IM to client B) instruct the client to schedule an annual pelvic examination C) tell the client she will start medication for HIV immediately after delivery D) report the clients condition to the local Heath department
D) report the clients condition to the local health department HIV is one of the conditions on the nationally notifiable infections conditions that is required to be reported
A nurse is evaluating a clients use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? A) the client places a crutch on each side when assuming a sitting position B) the client moves the unaffected leg into a step first when descending stairs C) the client places weight of the axillae when walking D) the client has slightly flexed elbows when ambulating with the crutches
D) the client has slightly flexed elbows when ambulating with the crutches
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the clients medical record? A) the client refused to take medication today B) the client stated "I will not take this pill" C) the client seemed angry and hostile D) the client threw the medication at the floor
D) the client threw the medication at the floor The nurse should document EXACTLY what took place for an accurate factual account of the events
A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? A) the client fully understands the providers explanation of the procedure B) the client has been informed about the risks and benefits of the procedure C) the nurse witnessed the providers explanation of the procedure D) the signature on the preoperative consent form is the clients
D) the signature in the preoperative consent form is the clients This is the nurse witnessing a signature of the client. It is the job of the physician to obtain consent by explaining the procedure along with the associated risks and benefits
What is secondary intention wound healing?
Wound is left open to drain and heal, which should occur within 5 to 21 days.
What is a penrose drain?
soft rubber tubing placed in a wound to prevent build up of fluid and allows for drainage