Read this 24

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations.

_____ color is positive for blood in fecal occult blood testing (guaiac test)?

Blue color

Wear what clothing while on oxygen?

Cotton b/c synthetic or wool fabrics can generate static electricity

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning?

Have the client demonstrates the procedure.

emergency if decannulation occurs?

in the 1st 72 hours

Palpate radial pulse for BP then?

inflate cuff another 30mmHg to hear BP systolic number

position for suppositories?

left lateral position

lubricate the distal 6-8 cm of suction catheter with a water-soluble lubricant for?

nasopharyngeal and nasotracheal suctioning

Suction pressure?

no higher than 120mmHg

Tracheostomy client permitted to eat?

position upright and tip chin to chest to enable swallowing

how often to remove TED hose?

remove and reapply at least twice a day

Positive test for ketones in urine?

uncontrolled blood glucose

Client in restraints assessed for food, fluids, comfort, and safety?

every 15-30 minutes

Blood glucose check on enteral feedings?

every 6 hours until max administration rate is reached and maintained for 24 hours

how often providing tacheostomy care?

every 8 hours

when to flush IVs?

every 8-12 hours when not in use

with continous-drip feeding, what must be done every 4-6 hours?

flush enteral tubing with 30-60mL of irrigant (tap water) and check tube placement

Hyperglycemia? Hypoglycemia?

greater than 250mg/dL---Less than 70mg/dL

Position for suctioning?

high-Fowlers or Fowlers position

Droplet precaution equipment?

Private room OR room with same disease client, masks for providers and visitors

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head is down, and he is wringing his hands. Which of the following actions should the nurse take?

Remain with the client

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift.

An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder.

Simple Face Mask?

40-60% at flow rate of 5-8L/min

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin

Rinne test?

Tuning fork against mastoid bone AC > BC 2-1 ratio

Weber Test

Tuning fork on top of client's head---sound heard equally in both ears---Negative Weber test

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal

delivers most precise oxygen concentration?

Venturi Mask: 24-55% at flow rates of 2-10L/min---Humidification not required

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3

Instillation of drops?

above conjunctival sac 1-2 cm, drop med into center of sac and hold pressure on nasolacrimal duct

Change IV site?

according to facility policy (usually 72 hours)

ethical principle of veracity

nurse tells client she has cancer

Assessment of respirations?

Rate, Depth (deep or shallow), and Rhythm (regular)

s/s of tachycardia?

pain, anxiety, restlessness, fatigue, low BP, and low O2 sat

Percussion on chest?

use cupped hand to clap rhythmically on chest to break up secretions

Parenteral site for infants and children < 2 years of age?

vastus lateralis site recommended

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you."

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order."

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?

"It must be difficult to care for someone who is confined to bed."

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities

Cane instructions?

2 points of support on ground at all times---Keep cane on stronger side---Move cane 6-10 in, then move weaker leg then stronger leg

Causes concern with UO < ___mL/hr?

< 30 mL/hr for more than 2 hours

Catheter embolus?

missing catheter tip when D/C, severe pain at site----Treat: tourniquet high on extremity to limit venous return, X-ray

Vibration on chest?

move heel of hands to create vibrations as the client exhales---cough after each set of vibrations

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

After age 2, what site can be used for parenteral injections?

ventral gluteal

when gastric residual exceeds 100mL?

withhold feeding and notify provider---maintain semi-Fowler's position

Fluids should not hang more than?

24 hours unless closed system

Nasal Cannula?

24-44% at flow rate of 1-6L/min----Humidification for flow rate 4L or >

Venturi Mask?

24-55% at flow rate of 2-10L/min via different size adaptors---most precise O2 concentration--humidification not required

monitoring tube replacement?

checking gastric contents for pH 0-4

what solutions used to clean trach?

hydrogen peroxide of normal saline

Prior to suctioning?

hyperoxygenate with FiO2 of 100%, obtain baseline vitals of O2 and breath sounds

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

"All of this equipment can be frightening."

Pulse strength scale?

0-4+---0=absent- 4+= full or bounding

body's preferred energy source?

Carbohydrates

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

-relief of urinary retention -measurement of residual urine after urination -presence of an open perineal wound

Tonsils grading scale?

1+ barely visible 2+ halfway to uvula 3+ touching uvula 4+ touching each other or midline

Normal pulse oximetry?

95%-100%---<85% is abnormal

Tympanic temperature--adults? children?

Adult--pull ear up and back; Children younger than 3 pull down and back

high humidification with O2 delivery?

Aerosol mask, face tent, and tracheostomy collar: 24-100% at flow rates of 10L/min or more

Sphygmomanometer?

BP measurement---Width should be 40% of arm circumference--Bladder (inside cuff) should surround 80% of arm circumference of adult and whole arm for child

Risk tools for Staging Pressure Ulcers?

Braden Scale <18---at risk; Norton Scale 15-16---indicator of risk

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit.

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?

Cough deeply after each use.

A nurse is planning care for a client who has terminal cancer and a prescription for morphine. Which intervention should the nurse include in the plan of care?

Instruct client to actively cough to prevent buildup of secretions in airway.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and wheelchair

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head.

A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Skin blanching

A nurse is reviewing a clients ABG lab results. Which of the following should the nurse report to the provider?

Sodium 126 mEq/L

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support.

Postural drainage?

client assumes one or more positions (total of 9) to allow gravity to assist with removal of secretions from specific areas of the lung

Serosanguineous drainage?

contains both serum and blood---watery and appears blood-streaks or blood-tinged

Evisceration?

dehiscence that involves the protrusion of visceral organs through a wound opening

Oxygen-induced hypoventilation?

develop in clients with COPD bc high levels of O2 can decrease or eliminate their respiratory drive

Serous drainage?

portion of the blood (serum) that is watery and clear or slightly yellow

Risk for infection at what injection site?

subcut and IM

Discontinue hot or cold applications?

usually 15-20 minutes

short term < 4 weeks enteral feeding?

nasogastric of nasointestinal tubes

Intermittent feeding?

60mL syringe---formula instilled via gravity until done followed with 60-100mL tap water

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown.

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1) Ask the client if he can bear weight 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside 2) Use the stand-and-pivot technique to move the client to the chair

Limit suction attempt to no longer than?

10-15 sec and 2-3 attempts with 20-30 sec for recovery between sessions

A nurse is caring for a client who has diabetes and a new prescriptions for 14 units of regular insulin and 28 units of NPH insulin to be given subcutaneous at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the syringe?

14 + 28 = 42 units.

Glasgow Coma scale?

15= awake and alert----3=coma

20/20?

1st # is distance pt is standing from Snellen chart--2nd # is distance a normal sighted person can read the line

Minimum degrees of bed while on enteral feeding?

30 degrees

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month-old infant can pull up to a standing position.

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has a cast and reports numbness and paresthesia

A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with her documentation.

A nurse is admitting a client who has active TB to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for this client?

A room with air exhaust directly to the outdoor environment

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions.

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

Assessment

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

Assist the client to an upright position.

Circadian rhythms?

BP usually lowest in the early morning and peaking during later part of afternoon

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Bounding pulse

Palpation of the thorax and lungs?

Chest excursion: thumbs move outward 5cm and Vocal (Tactile) Fremitus: client says 99 each time--vibration symmetrical

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing.

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

Evacuate the client

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag two-thirds full with ice.

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is assessing a client who is receiving TPN. Which of the following findings should the nurse recognize as a complication to this therapy?

Hyperglycemia

SaO2 < 90%?

Hypoxemia---Early: tachypnea, tachycardia, restlessness, pale skin, elevated BP---Late: confusion, cyanotic, bradypnea, bradycardia, hypotension, dysrhythmias

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

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?

Loss

Men respirations? Women respirations?

Men--diaphragmatic breathers, abdominal movements more noticeable--Women- thoracic muscles, and chest movements more pronounced

Highest O2 concentration possible?

Nonrebreather mask: 80-95% at flow rates of 10-15L/min

Insert catheter how?

Using the sterile hand

Crutch instructions?

Position crutches on unaffected side when sitting or rising from chair---support body weight at the hand grips with elbows flexed 30 degrees

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side.

Contact precaution equipment?

Private room OR room with same disease client, gloves and gowns by caregivers and visitors, disposal of infectious dressing material into single nonporous bag

Airborne precaution equipment?

Private room, N95 or HEPA respirator for TB, Negative pressure airflow exchange

Airborne precautions?

Protect against droplet infections smaller than 5mcg----Measles, varicella, pulmonary or laryngeal TB

The nurse overhears two AP's from the medical surgical unit discussing a hospitalized patient while in the cafeteria. Which of the following is the priority nursing action?

Quietly tell the AP's that that this is inappropriate

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion five times during each session.

A nurse is reviewing the ABG's for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid base balances?

Respiratory acidosis

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test

Hypoxemia?

SaO2 < 90%--s/s tachypnea, tachycardia, restlessness, anxiety, cyanosis----place in semi-Fowlers or Fowlers position

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

Semi-Fowler's

Rectal temperature?

Sims position---inserted 3.5cm or 11/2 in for adults

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers?

a client who has a protein calorie malnutrition a client who has right-sided heart failure and 4+ edema to lower extremities a client who has post operative delirium

Fidelity?

agreement to keep one's promise to the client about care that was offered

surgical asepsis for what suctioning?

all but suctioning of the mouth

Nonmaleficence?

avoidance of harm or pain as much as possible when giving treatments

Insert catheter?

bevel up at angle of 10-30 degrees----flash back of blood---lower hub of catheter close to skin to prepare for threading into vein 1/4 in---advance catheter into vein until hub rests against the insertion site

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which manifestations of Hypoglycemia

blurred vision / tachycardia / moist clammy skin

Phlebitis/thrombophlebitis?

edema, throbbing, burning, or pain at site, inc temp, erythema, red line up arm with palpable band at vein site, slowed infusion----Treat: D/C infusion and remove IV, elevate extremity, warm compress

MDI administration?

hold inhaler 1-2 inches away from mouth

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

The client holds his breath for 10 seconds after inhaling the medication

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

Hematoma?

Ecchymosis at site---Treat: No alcohol, apply pressure after IV removal, war compress and elevation after bleeding stops

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?

Edema at the infusion site

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults

Evisceration and Dehiscence requires?

Emergency treatment---cover wound and protruding organs with sterile towels soaked in sterile normal saline---DO NOT attempt to reinsert organs---position client supine with hips and knees bent

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure.

Assessment of pulse?

Rate, Rhythm (regular), Strength (amplitude 0-4), Equality (symmetrical)

Tracheal cuff pressure?

between 14-20 mmHg

signs of dysphagia?

coughing, choking, gagging, and drooling of food

Neurosensory checks and ROM in restraints?

every 2 hours

high risk for aspiration?

instruct client to tuck chin when swallowing

aspirate for residual volume?

intestinal should be less than 10mL and gastric should be less than 100mL---every 4-8 hours

Chest physiotherapy (CPT)?

involves chest percussion, vibration, and postural drainage to assist client to mobilize secretions---treatments 1hr before meals or 2hr after meals and at bedtime

Albumin levels < 3.5?

lack of protein puts client at risk for delayed wound healing and infection

what is used to cleanse peristomal area?

mild soap and water

Apical pulse?

5th intercostal space at left midclavicular line

Nonrebreather mask?

80-95% at flow rate of 10-15L/min to keep reservoir bag 2/3 full during I and E----one way valve allows client to inhale max O2 from reservoir bag

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway

Percussion of thorax and lungs?

Normal= resonance---Dullness= fluid or solid tissue, pneumonia or tumor---Hyperresonance= presence of air, pneumothorax or emphysema

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nurses using a friction-reducing device

Advance catheter until?

Urine returns then continue to advance it another 2.5-5cm

Diaphragm of stethoscope?

Used for high-pitched sounds (heart sounds, bowel sounds, breath sounds)---placed firmly on the body

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs."

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom. After assessing, the nurse notifies the provider. What documentation should the nurse use?

"The provider was notified."

A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Which of the following should the nurse give the AP's about the clients' use of a cane?

"When the client moves, he should move the cane forward first."

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this."

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/ 1 mL. How many mL should the nurse administer per dose?

40 / 10 = 4 mL

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver Damage

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position.

Sanguineous drainage?

contains serum and RBCs---thick and appears reddish

selecting vein for IV insertion?

distal veins first on nondominant hand--soft and bouncy feeling when palpated

Fluid Overload?

distended neck veins, increased BP, tachycardia, SOB, crackles and edema----Treat: Stop infusion, raise HOB, VS, adjust rate, Diuretics if prescribed

how to take apical pulse?

5th intercostal space at left midclavicular line--place stethoscope on chest and always count for 1 minute----used to assess HR of infant, rapid rates > 100, irregular rhythms, and prior to cardiac meds

Unused formula after 24 hours?

discarded

Partial rebreather mask?

60-75% at flow rate of 6-11L/min---reservoir bag attached with no valve which allows client to rebreathe up to 1/3 of exhaled air

A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include?

People who practice Judaism stay with the body of the deceased until burial.

Purulent drainage?

result of infection---thick and contains WBCs, tissue debris, and bacteria

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent?

surgeon

s/s of bradycardia?

hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental status

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you."

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

Eggs

Beneficence?

agreement that the care given is in the best interest of the client---positive actions

Dehiscence?

partial or total rupture of sutured wound

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)

Narrowed arterial lumen (Bruit)

Bell of stethoscope?

Used for low-pitched sounds (abnormal heart sounds, bruits)---placed lightly on the body

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity.

Cellulitis?

pain, warmth, edema, induration, red streaking, fever, chills, and malaise-----Treat: D/C and remove IV, elevate extremity, warm compress, culture

Infiltration?

pallor, local swelling, dec skin temp, damp dressing, slowed infusion----Treat: stop infusion and remove IV, elevate extremity, warm compress

Droplet precautions?

protect against droplets larger than 5mcg---streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia/sepsis, pneumonic plague

Contact Precaution?

protect visitors and caregivers against direct client/environment contact infections---respiratory syncytial virus, shigella, enteric diseases caused by micros, wound infections, herpes simplex, scabies, multidrug-resistant organisms