Quiz #1 (Ch. 1, 2, 3, 11, 13, 14, 15, 16)

Positive Trousseau's and Chvostek's signs are associated with?

-hypocalcemia -hyperphosphatemia.

Paresthesia with sensations of tingling and numbness is associated with?

-hypophosphatemia -hypercalcemia

A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) ____ mL/hr

42 (1000 mL ÷ 24 hours = 41.6 mL/hr.)

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?a. A 34-year-old on NPO status who is receiving intravenous D5W b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

A 34-year-old on NPO status who is receiving intravenous D5W

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this client's teaching? a."You will need to wear a sling on your arm while the device is in place." b."There is no risk of infection because sterile technique will be used during insertion." c."Ask all providers to vigorously clean the connections prior to accessing the device." d."You will not be able to take a bath with this vascular access device."

"Ask all providers to vigorously clean the connections prior to accessing the device."

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching? a."Avoid carrying your grandchild with the arm that has the central catheter." b."Be sure to place the arm with the central catheter in a sling during the day." c."Flush the peripherally inserted central catheter line with normal saline daily." d."You can use the arm with the central catheter for most activities of daily living."

"Avoid carrying your grandchild with the arm that has the central catheter."

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond? a. "Potatoes and avocados can be substituted for fruit." b. "If you cook the fruit, the amount of potassium will be lower." c. "Berries, cherries, apples, and peaches are low in potassium." d. "You are correct. Fruit is very high in potassium."

"Berries, cherries, apples, and peaches are low in potassium."

A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best? a. "All staff nurses are required to participate in quality improvement here." b. "Even being new, you can implement activities designed to improve care." c. "It's easy to identify what indicators should be used to measure quality." d. "You should ask to be assigned to the research and quality committee."

"Even being new, you can implement activities designed to improve care."

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? a."Grade 3 phlebitis at IV site" b."Infection at IV site" c."Thrombosed area at IV site" d."Infiltration at IV site"

"Grade 3 phlebitis at IV site"

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. "Cut some sodium out of your diet." b. "Dehydration can cause incontinence." c. "Have something to drink every 1 to 2 hours." d. "Take your diuretic in the morning."

"Have something to drink every 1 to 2 hours."

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. "I have had the same best friend for decades." b. "I think I am coping very well on my own." c. "My kids come to see me every weekend." d. "Oh, I have lots of friends at the senior center."

"I have had the same best friend for decades."

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates the client correctly understood the teaching? a. "I must drink a quart of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 PM so I won't have to get up at night."

"I will weigh myself each morning before I eat or drink."

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching? a. "Weigh yourself every morning and every night." b. "Check your radial pulse twice a day." c. "Read food labels to determine sodium content." d. "Bake or grill the meat rather than frying it."

"Read food labels to determine sodium content."

A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a."Provide a bed bath instead of letting the client take a shower." b."Use sterile technique when changing the dressing." c."Disconnect the intravenous fluid tubing prior to the client's bath." d."Use a plastic bag to cover the extremity with the device."

"Use a plastic bag to cover the extremity with the device."

A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult's kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements

-1% milk -Carrots -Oranges -Vitamin D supplements

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

-A 36-year-old who is malnourished -A 42-year-old with uncontrolled diabetes -A 76-year-old who is prescribed antacids

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last month's visit. What actions should the nurse perform first? (Select all that apply.) a. Assess the client's ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.

-Assess the client's ability to drive or transportation alternatives. -Determine if the client has dentures that fit appropriately. -Have the client complete a 3-day diet recall diary.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off. e. Give raises based on compliance with reporting.

-Attend hand-off rounds to coach and mentor. -Conduct audits of staff using a new template. -Create a template of topics to include in report. -Encourage staff to ask questions during hand-off.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interdisciplinary team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care

-Collaborating with an interdisciplinary team -Implementing evidence-based care -Routinely using informatics in practice -Using quality improvement in client care

A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders

-Confusion -Incontinence -Sleep disorders

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness

-Constipation -Dehydration -Weakness

A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress e. Shows the nursing care plans to other disciplines

-Consults with other disciplines on client care -Coordinates discharge planning for home safety -Participates in comprehensive client rounding -Routinely asks other disciplines about client progress

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

-Electrocardiogram changes -Paralytic ileus -Skeletal muscle weakness

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain

-Exhaustion -Slowed physical activity -Weakness

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia - Flaccid paralysis with respiratory depression b. Hyperphosphatemia - Paresthesia with sensations of tingling and numbness c. Hyponatremia - Decreased level of consciousness d. Hypercalcemia - Positive Trousseau's and Chvostek's signs e. Hypomagnesemia - Bradycardia, peripheral vasodilation, and hypotension

-Hypokalemia - Flaccid paralysis with respiratory depression -Hyponatremia - Decreased level of consciousness

A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a.Include a review for the need of the device each day in the client's plan of care. b.Remind the provider to perform hand hygiene prior to starting the procedure. c.Cleanse the preferred site with alcohol and let it dry completely before insertion. d.Ask everyone in the room to wear a surgical mask during the procedure. e.Plan to complete a sterile dressing change on the device every day.

-Include a review for the need of the device each day in the client's plan of care. -Remind the provider to perform hand hygiene prior to starting the procedure. -Ask everyone in the room to wear a surgical mask during the procedure.

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness

-Increased pulse rate -Distended neck veins -Skeletal muscle weakness

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the client's skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

-Keep the client's skin dry. -Obtain a pressure-relieving mattress. -Turn the client every 2 hours.

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse's expertise c. Client preferences d. Research findings e. Values of the client

-Nurse's expertise -Client preferences -Research findings -Values of the client

Potassium chloride intravenously is ordered for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply 1. Obtain an IV infusion pump 2. Monitor urine output during administration 3. Prepare the medication for the bolus administration 4. Monitor the IV site for infiltration and phlebitis 5. Ensure the medication is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

-Obtain an IV infusion pump -Monitor urine output during administration -Monitor the IV site for infiltration and phlebitis -Ensure the medication is diluted in the appropriate volume of fluid -Ensure that the bag is labeled so that it reads the volume of potassium in the solution

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration. Select all that apply 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage

-Pallor and coolness -Numbness and pain -Edema and blanched skin

A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.

-Perform and document results of a Braden Scale assessment. -Request a dietary consultation from the health care provider. -Suggest a high-protein oral supplement between meals.

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) a.Phlebitis b. Pneumothorax c. Thrombophlebitis d.Excessive bleeding e. Extravasation

-Phlebitis -Thrombophlebitis

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L

-Serum potassium level of 5.4 mEq/L -Blood osmolality of 250 mOsm/L

Potential complications of hypokalemia include (select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

-Slow, shallow respirations -Orthostatic hypotension

A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.) a.State Nurse Practice Act b.The facility's Policies and Procedures manual c.The LPN's level of education and experience d.The Joint Commission's goals and criterion e.Client needs and prescribed orders

-State Nurse Practice Act -The facility's Policies and Procedures manual

After administering 40 mEq of potassium chloride, a nurse evaluates the client's response. Which manifestations indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

-Strong productive cough -Active bowel sounds

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Product code

-Unique facility identifier -Lot number related to the donor -ABO group and Rh type of the donor -Product code

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this client's care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

-Use a draw sheet to reposition the client in bed. -Provide nonslip footwear for the client to use when out of bed.

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure

A 76-year-old who is cognitively impaired

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy should the nurse assess this client? a.Allergic reaction b.Bowel obstruction c.Catheter lumen occlusion d.Infection

Infection

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary care provider. d. Repeat blood pressure measurement in 15 minutes.

Call the Rapid Response Team.

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. -Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. -Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. -Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. -Dr. Smith Based on the information provided, which action should the nurse take? a.Notify the health care provider. b.Administer the prescribed medication. c.Discontinue the PICC. d.Switch the medication to the oral route.

Administer the prescribed medication.

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes should the nurse use to draw up and administer the heparin?

Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC.

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) b. Anxious client who has tachypnea c. Client who is on fluid restrictions d. Client who is constipated with abdominal pain

Anxious client who has tachypnea

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler's position.

Apply oxygen by mask or nasal cannula.

Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent b. Gives the client accurate information when questioned c. Keeps the promises made to the client and family d. Treats the client fairly compared to other clients

Asks if the client has questions before signing a consent

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

Assess the client's respiratory rate, rhythm, and depth.

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care b. Ensures that all the clients' basic needs are met c. Tells the client and family about all upcoming tests d. Thoroughly orients the client and family to the room

Assesses for cultural influences affecting health care

A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. A: "I would like you to order a different pain medication." b. B: "This client has allergies to morphine and codeine." c. R: "Dr. Smith doesn't like non-steroidal anti-inflammatory meds." d. S: "This client had a vaginal hysterectomy 2 days ago."

B: "This client has allergies to morphine and codeine."

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the doctor's phone number by the telephone. c. Make sure all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.

Bring a list of all medications and what they are for.

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training

Building strength and flexibility

A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a.Check for kinking of the catheter. b.Flush the catheter with a thrombolytic enzyme. c.Get a new infusion pump. d.Remove the IV catheter.

Check for kinking of the catheter.

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

Client with pancreatitis who has continuous nasogastric suctioning

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin (Calcimar).

Connect the client to a cardiac monitor.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

Dangle the client on the bedside before ambulating.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness

Decreased orthostatic light-headedness and dizziness

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

Depth of respirations

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

Determine if there are new medications.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the client's family sign the consent.

Discuss concerns with the health care team.

A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don't make assumptions about their health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

Don't make assumptions about their health needs.

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

Encourage the client and family to be active partners.

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a.Begin the prescribed infusion via the new access. b.Ensure an x-ray is completed to confirm placement. c.Check medication calculations with a second RN. d.Make sure the solution is appropriate for a central line.

Ensure an x-ray is completed to confirm placement.

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

Ensuring client safety

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim

Exercise program to improve physical function

The SPICES framework is a comprehensive list of what can go wrong in a hospitalized older adult. True False

False (its a mnemonic device covering "geriatric vital signs" that, taken together, provide a good overview of a geriatric patient's response to the care given and point to the need for more detailed assessment when necessary)

A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that is accredited by The Joint Commission. d. Use a facility affiliated with a medical or nursing school.

Find a hospital that is accredited by The Joint Commission.

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? a.Initiate a dedicated team to insert access devices. b.Require additional education for all nurses. c.Limit the use of peripheral venous access devices. d.Perform quality control testing on skin preparation products.

Initiate a dedicated team to insert access devices.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole wheat crackers d. Grilled chicken breast with glazed carrots

Grilled chicken breast with glazed carrots

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

Install contrasting color strips at the edge of each step.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in bed.

Keep the light on in the bathroom at night.

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine? a. Cyclobenzaprine (Flexeril) b. Hydromorphone hydrochloride (Dilaudid) c. Ketorolac (Toradol) d. Meperidine (Demerol)

Meperidine (Demerol) (Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride.)

The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75Eq/L. Which action should the nurse take? 1.Monitor the client for irregular hear rhythms 2.Encourage the intake of antacids with phosphate? 3.Teach the client to avoid food high in magnesium 4.Provide the diet of ground beef, eggs an chicken breast

Monitor the client for irregular heart rhythms

The ______________ project helps hospitals assess the quality of care they give to older adults and provides four nursing-care models, evidence-based protocols for assessing older adults, and educational materials to help hospitals implement effective systemic changes.

NICHE (Nursing Improving Care for Health System Elders)

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old

Old old

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

Perform an oral assessment.

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure? a.Lower the extremity below the level of the heart. b.Apply warm compresses to the extremity. c.Tap the skin lightly and avoid slapping. d.Place a washcloth between the skin and tourniquet.

Place a washcloth between the skin and tourniquet.

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a.Administer topical lidocaine to the site. b.Place warm compresses on the site. c.Administer prescribed oral pain medication. d.Massage the site with scented oils.

Place warm compresses on the site.

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. b. Provide a heart healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a.Administer a sublingual nitroglycerin tablet. b.Prepare to assist with chest tube insertion. c.Place a sterile dressing over the IV site. d.Re-position the client into the Trendelenburg position.

Prepare to assist with chest tube insertion.

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a.Amount of pressure in fluid container b.Date of catheter tubing change c.Percent of heparin in infusion container d.Presence of an ulnar pulse

Presence of an ulnar pulse

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the UAP knew how to take blood pressure b. Double-checking the UAP by taking another blood pressure c. Providing more appropriate supervision of the UAP d. Taking the blood pressure instead of delegating the task

Providing more appropriate supervision of the UAP

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying "Those are for old people." What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

Put color-coded stickers on the bottle caps.

The nurse is assessing a client's peripheral IV site after completion of a vancomycin infusion and notes that the area is redden, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. Check for the presence of blood return 2. Remove the IV site and restart at another site. 3. Document the findings and continue to monitor the IV site. 4. Call the hcp and request that the vancomycin be given orally

Remove the IV site and restart at another site

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a.Redness at the catheter insertion site b.Report of headache and stiff neck c.Temperature of 100.1° F (37.8° C) d.Pain rating of 8 on a scale of 0 to 10

Report of headache and stiff neck

A nurse admits an older client from a home environment where she lives with her adult son and daughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.

Report the findings as per agency policy.

An older adult recently retired and reports "being depressed and lonely." What information should the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adult's life d. Usual leisure time activities

Role of work in the adult's life

The _____________ assessment done regularly, can signal the need for more specific assessment and lead to the prevention and treatment of common "marker conditions" for older patients rather than on the disease or injury for which a patient was hospitalized.

SPICES

After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk

SPICES

Sleep disorders Problems with eating or feeding Incontinence Confusion Evidence of falls Skin breakdown

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a.Apply cold compresses to the IV site. b.Elevate the extremity on a pillow. c.Flush the catheter with normal saline. d.Stop the infusion of intravenous fluids.

Stop the infusion of intravenous fluids.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a.The catheter has been in place for 20 hours. b.The client has poor vascular access in the upper extremities. c.The catheter is placed in the proximal tibia. d.The client's left lower extremity is cool to the touch.

The client's left lower extremity is cool to the touch.

The nurse is assessing a client diagnosed with a suspected hypocalcemia. Which clinical manifestation would the nurse expect to note in this client? 1. Twitching 2. Hypoactive bowel sounds 3. negative trousseau's sign 4. Hypoactive deep tendon reflexes

Twitching

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a.The initial site dressing is 3 days old. b.The PICC was inserted 4 weeks ago. c.A securement device is absent. d.Upper extremity swelling is noted.

Upper extremity swelling is noted.

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole wheat bread

White rice

The presence of the SPICES conditions, alone or in combination, can lead to what 3 things in elderly patients

death rates higher costs longer hospitalizations

Bradycardia, peripheral vasodilation, and hypotension are associated with?

hypermagnesemia

A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of?

hypokalemia

A PICC that is functioning well without inflammation or infection may remain in place for how long?

months or even years