Prep U + Definitions Foundations of Nursing (Chapter 15, 16, 18, 25, 32, 34) Test 1

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?

"We need to validate the information obtained in this assessment." Rationale: The assessment of a toddler should involve the parents, as they are the primary caretakers and most knowledgeable about their toddler's normal behavior and development, as well as the history of any presenting symptoms. The nurse will validate assessment data to verify information and clarify cues and inferences to determine if they are accurate and free of bias. Crackles indicate the presence of fluid in the airways. Client information is shared only with those caregivers who have a need to know the information. Nurses have a duty to teach the parents about their toddler's symptoms.

A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply. Candida albicans Staphylococcus aureas E. coli Norovirus Clostridium difficile

-Clostridium difficile -Norovirus Explaination: Alcohol-based products are not effective against Clostridium difficile or Norovirus. Therefore, handwashing with soap and water is required for any contact with a client who has diarrhea. Use of alcohol-based products are appropriate for clients with infections involving Staphylococcus aureas, candida, and E. coli.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care Rationale: The nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?

Consultation Rationale: The client's health care provider may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a health care provider by asking specific questions, either of the client or of other people who know the person and can give suitable information.

Which of the following are considered the building blocks of the immune system? Macrophages T lymphocytes Macrocytes Red blood cells

T-lymphocytes

Tertiary (Rehab)

begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Examples: teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury, and referring a woman to a support group after removal of breast because of cancer, and occupational therapy.

Primary (prevention)

directed toward promoting health and preventing the development of disease processes or injury. Examples: immunization clinics, family planning services, poising control information, and accident-prevention education.

Secondary (screening)

focus on screening for early detection of disease with prompt diagnosis and treatment of any found. Examples: assessing children for normal growth and development and encouraging regular medical, dental and vision examinations, mammogram

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control? sterile gauze handwashing sterile gloves clean environment

handwashing

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

inspection Rationale: When the nurse performs a physical assessment, four techniques: inspection, palpation, percussion, and auscultation will be used. In most cases the nurse will perform them in sequence. Because palpation and percussion can alter bowel sounds, the nurse will inspect, auscultate, percuss, then palpate an abdomen.

The local high school has been exposed to methicillin-resistant Staphylococcus aureus (MRSA) infection and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include? Select all that apply. go to see your health care provider for cold-like symptoms use of hand sanitizer when necessary keep draining wounds covered online research on MRSA 20-second handwashing

use of hand sanitizer when necessary keep draining wounds covered online research on MRSA 20-second handwashing

The school nurse is educating a group of teenagers about ways in which human immunodeficiency virus (HIV) can be transmitted. Which methods of infection transmission will the nurse educate the group about? Select all that apply. via sexual contact contact with blood via syringes shared between the client and others contact with sweat via mucous membranes contact with wound openings

via contact with blood via sexual contact via contact with wound openings via mucous membranes via syringes shared between the client and other