214 REVIEW

A home health care nurse is teaching a patient and caregivers how to administer an enteral feeding. Which teaching points are appropriate? (Select all that apply.) Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall. Check for leaking of gastric contents around the insertion site (is guard too loose or balloon not filled adequately?). Keep the head elevated while delivering a gastric feeding and for approximately an hour after the feeding. When cleaning around a gastric tube insertion site, be careful not to rotate the guard after cleaning around it. When checking residuals, routinely discard residuals to prevent an acid-base imbalance. Clean around the gastric tube with soap and water, making sure it is adequately rinsed.

Check for leaking of gastric contents around the insertion site (is guard too loose or balloon not filled adequately?). Clean around the gastric tube with soap and water, making sure it is adequately rinsed. Keep the head elevated while delivering a gastric feeding and for approximately an hour after the feeding. Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall.

The nurse is caring for a client with a central venous line. Which nursing action(s) should be implemented in the plan of care for chemotherapy administration? Select all that apply. Verify patency of the line by the presence of a blood return at regular intervals. Inspect the insertion site for swelling, erythema, or drainage. Contact the health care provider about verifying placement if the status is questionable. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present. Reposition the client if unable to aspirate blood, and encourage the client to cough.

Verify patency of the line by the presence of a blood return at regular intervals. Inspect the insertion site for swelling, erythema, or drainage. Contact the health care provider about verifying placement if the status is questionable. Reposition the client if unable to aspirate blood, and encourage the client to cough.

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is "How do you manage your stress?" "Is stress a problem in your life?" "Do you feel stress at work?" "How often do you feel stressed?"

"How do you manage your stress?"

The nurse is planning care for a client with human immunodeficiency virus (HIV). Which statement by the nurse indicates understanding of HIV transmission? Select all that apply. "I will wear a gown, mask, and gloves with all client contact." "I don't need to wear any personal protective equipment due to decreased risk of occupational exposure." "I will wear a mask if the client has a cough caused by an upper respiratory infection." "I will wear a mask, goggles, gown, and gloves when splashing bodily fluids is likely." "I will wash my hands after client care."

"I will wear a mask, goggles, gown, and gloves when splashing bodily fluids is likely." "I will wash my hands after client care."

A nurse is evaluating a patient's discharge collaboration between the referring agency and the home care agency. What response by the patient would indicate an understanding of the discharge planning process? "The doctor provided a list of behavioral outcomes for me and his nurse faxed them to the home care agency." "The nurse helped me make a list of my needs and goals for recovery and shared them with the home care team."

"The nurse helped me make a list of my needs and goals for recovery and shared them with the home care team."

Magnesium range

1.3-2.5

To calculate the ideal body weight for a woman, the nurse allows

100 pounds for 5 feet of height. 106 pounds for 5 feet of height in calculating the ideal body weight for a man.

Potassium

3.5-5.0

WBC count

5,000-10,000

BMI

703 X WEIGHT IN POUNDS / HEIGHT IN INCHES(squared) ex. 195lb. 6Ft tall. 6x12=72". 72X72= 5184 195/5184=0.0376 x 703 = 26

Calcium range

8.5-10.5

Which examples of patients would the nurse expect to have an increase in BMR? (Select all that apply.) An elderly patient who is in a long-term care facility An adolescent who has a fever A teenager who has been fasting to lose weight An adult who is going through an emotional time due to divorce An adult who has hypersomnia A toddler who is having a growth spurt

An adolescent who has a fever A toddler who is having a growth spurt An adult who is going through an emotional time due to divorce

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) Call bell within reach Correct intravenous lines and fluids Bed at mid-level, locked position Correct tubes and drains intact Wearing client identification bracelet

Call bell within reach Correct intravenous lines and fluids Correct tubes and drains intact Wearing client identification bracelet

A nurse is caring for a patient receiving parenteral nutrition at home. The patient was discharged from the acute care facility 4 days ago. Which of the following would the nurse include in the patient's plan of care? Select all that apply. Daily transparent dressing changes Calorie counts for oral nutrients Intake and output monitoring Daily weights Strict bedrest

Calorie counts for oral nutrients. Intake and output monitoring Daily weights

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? Call the physician. Apply a dry sterile dressing to the site. Tell the client to take and hold a deep breath. Clamp the catheter.

Clamp the catheter.

The nurse reviews data collected during an assessment. Which data should the nurse validate? Select all that apply. Gap between what the client said and what is in the medical record Subjective and objective data are inconsistent Evening temperature higher than morning temperature Data that is inconsistent with another finding Respiratory rate slower during sleep than while awake

Data that is inconsistent with another finding Subjective and objective data are inconsistent. Gap between what the client said and what is in the medical record.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by which of the following? Increasing ventilation through the lungs Preventing excretion of acids into the urine Increasing the excretion of H ion into the urine Increasing the excretion of HCO into the urine

Increasing ventilation through the lungs

Which of the following measures are used by the nurse to confirm the correct placement of a nasogastric feeding tube? Select all that apply. Monitoring carbon dioxide levels Auscultating injected air Measuring tube length Measuring the pH level of aspirated contents Instilling fluid into the tube

Monitoring carbon dioxide levels Measuring tube length Measuring the pH level of aspirated contents

A client receiving chemotherapy for cancer has an elevated serum creatinine level. What should the nurse do next? Cancel the next scheduled chemotherapy. Obtain a urine specimen. Notify the health care provider (HCP). Administer the scheduled dose of chemotherapy.

Notify the health care provider (HCP).

One hour after a transfusion of packed red cells is started; a patient develops redness on his trunk and complains of itching. The nurse stops the red blood cell (RBC) infusion and administers the ordered diphenhydramine (Benadryl) 25 mg po. Thirty minutes later, the redness and itching is gone. What is the next action the nurse should take? Obtain blood and urine samples from the patient Send the blood back to the blood bank Resume the transfusion Position the patient in an upright position with the feet in a dependent position

Resume the transfusion

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? Kussmaul respirations Increased DTRs Hypertension Shallow respirations

Shallow respirations *If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness.

A client is receiving a transfusion of packed red blood cells. What should the nurse do to safely administer the blood? Do not infuse blood that has been hanging for more than 6 hours. Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. Keep the blood refrigerated on the nursing unit until ready to administer. Administer the blood quickly to prevent wasting it if the client develops a fever.

Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.

A 36-year-old man is receiving three different chemotherapeutic agents for Hodgkin's disease. The nurse explains to the client that the three drugs are given over an extended period because: The first two drugs are toxic to cancer cells, and the third drug promotes cell growth. The three drugs can be given at lower doses. The three drugs have a synergistic effect and act on the cancer cells with different mechanisms. The second and third drugs increase the effectiveness of the first drug.

The three drugs have a synergistic effect and act on the cancer cells with different mechanisms.

A positive nitrogen balance indicates which of the following conditions? Fever Burn injury Starvation Tissue growth

Tissue growth *A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth. A negative nitrogen balance exists with fever, starvation, and burn injury.

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data? To communicate effectively with other health care team members To provide protection from liability in the case of a lawsuit To avoid penalties imposed by the federal government To aid the nurse's recall of client information

To communicate effectively with other health care team members

Venturi mask

an oxygen-delivery apparatus consisting of a mask with holes on each side that allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow regulation of the concentration of oxygen delivered

The nurse is administering an intravenous (IV) infusion of packed red blood cells and normal saline solution to a client who is in hemorrhagic shock. Which is a priority for the nurse to assess for this client? altered level of consciousness fluid balance anaphylactic reaction pain

anaphylactic reaction

When integrating the total physical examination the nurse should perform the Mental Status Exam after examining all other body systems. assess peripheral vascular status when examining the lower extremities. integrate the rectal examination with the abdominal examination. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time.

assess peripheral vascular status when examining the lower extremities.

The nurse is working at the local family planning clinic completing family education. When devising a teaching plan, in which client group would the nurse stress the importance of an annual Papanicolaou test? clients infected with the human papillomavirus (HPV) clients with a long history of oral contraceptive use clients with a history of recurrent candidiasis clients who were pregnant before age 20

clients infected with the human papillomavirus (HPV)

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent which outcome? depriving the client of sufficient oxygen supply dislodging the tracheostomy tube obstructing the suctioning catheter with secretions stimulating the client's cough reflex

depriving the client of sufficient oxygen supply

The nurse is performing a general survey as part of a comprehensive health assessment. When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with? apparent age developmental stage stated age vital signs

developmental stage

Waist circumference indicative of excess abdominal fat

greater than 40 inches for men or 35 inches for women increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.

A client with cancer is receiving radiation therapy and develops thrombocytopenia. What is the priority nursing goal to prevent which effect of thrombocytopenia for this client?

injury related to the decreased platelet count *This client is at high risk for bleeding because of the decreased platelet count. The priority nursing goal is to prevent injury to this client by preventing bleeding occurrences. Spontaneous bleeding may cause pain, but it is not the priority. The client has a low platelet count, not a low hemoglobin count such as exists in anemia. Skin integrity is a risk but not a priority.

The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client reports headache and nausea. Based on the serum laboratory results, how would the nurse interpret the client's acid-base balance? :metabolic alkalosis metabolic acidosis

metabolic acidosis *This client has metabolic acidosis, which typically manifests with a low pH, low bicarbonate level, normal to low PaCO2, and normal PaO2. The client's serum electrolyte levels also support metabolic acidosis, which include an elevated potassium level, normal to elevated chloride level, and normal calcium level. The client's anion gap of 30 mEq/L is high, also indicative of metabolic acidosis. This kind of metabolic acidosis occurs with diabetic ketoacidosis and other disorders.

A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? metabolic alkalosis and hypokalemia metabolic alkalosis and hyperkalemia metabolic acidosis and hyperkalemia metabolic acidosis and hypokalemia

metabolic alkalosis and hypokalemia

A nurse is teaching a community class about how to decrease the risk of cancer. What is the best food for the nurse to recommend?

oranges A diet high in vitamin C and citrus may help reduce the risk of certain cancers, such as stomach and esophageal cancers. Hot dogs and foods that are smoked and cured are high in nitrates, which may be linked to esophageal and gastric cancers. The chemical process used to decaffeinate coffee contributes to cancer.

A client is to receive intravascular chemotherapy for 10 days. Which equipment should the nurse use for this procedure? intravenous catheter insertion device peripherally inserted central catheter (PICC)

peripherally inserted central catheter (PICC)

A client with cancer is receiving radiation therapy and develops thrombocytopenia. What is the priority nursing goal to prevent which effect of thrombocytopenia for this client? pain related to spontaneous bleeding episodes altered nutrition related to anemia injury related to the decreased platelet count skin breakdown related to decreased tissue perfusion

skin breakdown related to decreased tissue perfusion

A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the situation, background, assessment, and recommendation (SBAR) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment? transferring the child to pediatric intensive care starting oxygen

starting oxygen

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to ensure efficient and accurate communication to prevent medication errors to ensure client safety to make it easier for clients to understand the medication prescriptions to make data entry into a computerized health record easier

to ensure efficient and accurate communication to prevent medication errors to ensure client safety

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? "Gloves help protect you against infectious organisms." "Gloves are required for standard precautions."

"Gloves are required for standard precautions."

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? "The younger you are when you start smoking, the higher your risk of lung cancer." "The risk for lung cancer is determined mostly by what type of cigarettes you smoke." "The risk for lung cancer depends primarily on the other risk factors for cancer that you have." "The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays."

"The younger you are when you start smoking, the higher your risk of lung cancer."

Conflict has emerged on a nursing unit due to the perception by new graduates that some of the more experienced nurses are manipulating the patient assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict? Gather evidence over the next several weeks in order to determine if the practice is indeed happening Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible

Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible

The nurse is assessing adequate nutrition for residents of a long-term care facility. Which strategies are recommended to address age-related changes affecting nutrition? (Select all that apply.) Eat more protein for lowered glucose tolerance. Avoid eating right before bedtime for gastroesophageal reflux. Avoid cold liquids with decreased peristalsis in the esophagus. Serve a variety of foods at each meal for loss of sense of taste and smell. Offer large meals at frequent intervals for reduction in appetite and thirst sensation. Eat a high-fiber diet for slowed intestinal peristalsis.

Avoid eating right before bedtime for gastroesophageal reflux. Avoid cold liquids with decreased peristalsis in the esophagus. Eat a high-fiber diet for slowed intestinal peristalsis.

Personal protective equipment for use with standard precautions includes which of the following items? Select all that apply. Face mask Disposable gloves Eye protection Fluid-repellent gown Disposable shoe covers Disposable head cover

Face mask Disposable gloves Eye protection Fluid-repellent gown

Which factors have been identified as primary causes of falls? Select all that apply. Benzodiazepine use Poor lighting Environmental hazards History of previous falls Chronic illness Irregular heart rate

Benzodiazepine use Poor lighting Environmental hazards History of previous falls

You are preparing to administer an intermittent feeding to a patient who has a feeding tube. You are unable to aspirate gastric contents. Which of the following actions is correct? Select all that apply. Mix meat tenderizer with 30 mL warm water, instill into the feeding tube, wait 15 minutes, then flush vigorously. Check to see that the feeding tube clamp is open. Advance the tube no more than 4 inches, auscultate for bowel sounds, then attempt to aspirate again. Insert a stylet until resistant is felt, then gently rotate the stylet until resistance decreases. Connect a syringe filled with warm water to the feeding tube and apply gentle pressure.

Check to see that the feeding tube clamp is open. Connect a syringe filled with warm water to the feeding tube and apply gentle pressure.

A nurse is teaching a client about nutrition. Which of the following facts should the nurse include about fat-soluble vitamins? Select all that apply. Deficiencies of fat-soluble vitamins can occur with malabsorption syndromes. Fat-soluble vitamins are A, D, E, and K. Fat-soluble vitamins must be attached to a protein for transport in the blood. The body excretes all excess water-soluble vitamins. Deficiencies may take hours or days to develop.

Deficiencies of fat-soluble vitamins can occur with malabsorption syndromes. Fat-soluble vitamins are A, D, E, and K. Fat-soluble vitamins must be attached to a protein for transport in the blood.

Which nursing actions follow guidelines for preventing complications with enteral feedings? (Select all that apply.) Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. Change the delivery set every other day according to agency policy. Flush the tube before and after feeding. Check the residual before intermittent feedings and every 8 hours during continuous feedings. Give large, infrequent feedings. Clean and moisten the nares every 4 to 8 hours.

Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. Flush the tube before and after feeding Clean and moisten the nares every 4 to 8 hours.

A dialysis unit nurse caring for a patient with renal failure will expect the patient to exhibit which fluid and electrolyte imbalances? Fluid volume excess and acidosis Fluid volume deficit and alkalosis Fluid volume deficit and acidosis Fluid volume excess and alkalosis

Fluid volume excess and acidosis

When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply. Health status Motivation for learning Telephone access Marital status Family support

Health status Motivation for learning Telephone access Family support

Arterial blood gases reveal that a patient's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? Renal retention of Hions Hypoventilation Increased respiratory rate Increased excretion of bicarbonate ions by the kidneys

Increased respiratory rate *Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis.

During a tube feeding, the nurse visualizes aspirated contents, checking for color and consistency. Which of the following are normal findings? Select all that apply. Intestinal aspirate may be black if stained with bile. A small amount of mucus may be seen immediately after NG insertion. Intestinal aspirate tends to look clear or straw-colored to a deep golden-yellow color. Respiratory or tracheobronchial fluid is usually off-white to tan. Respiratory or tracheobronchial fluid may be tinged with blood. Gastric fluid can be green with particles, off-white, or brown if old blood is present.

Intestinal aspirate tends to look clear or straw-colored to a deep golden-yellow color. Respiratory or tracheobronchial fluid is usually off-white to tan. Gastric fluid can be green with particles, off-white, or brown if old blood is present

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? Keep the tracheostomy tube plugged at all times. Deflate the cuff overnight to prevent tracheal tissue trauma. Inflate the cuff to the highest possible pressure in order to prevent aspiration. Monitor the pressure in the cuff at least every 8 hours

Monitor the pressure in the cuff at least every 8 hours

A nurse has assessed the residual amount before beginning a nasogastric tube feeding and has found 100 mL. What will the nurse do next? Nothing; this amount is within normal limits. Omit the feeding and document the reason. Report the finding to the physician. Rinse the tube and repeat the assessment.

Nothing; this amount is within normal limits. A residual of more than 200 mL for a nasogastric tube and 100 mL for a gastrostomy tube may indicate that the feeding should be interrupted or delayed for 30 to 60 minutes. A finding of 100 mL is within normal limits; the nurse should administer the tube feeding.

A nurse is removing an NG tube and notes epistaxis. What nursing interventions would the nurse perform in this situation? (Select all that apply.) Record the amount of blood in the suction container. Occlude both nares until bleeding has subsided. Document epistaxis in patient's medical record. Ensure that patient is in upright position. Notify primary care provider and anticipate order to reinsert NG tube. Offer facial tissue to blow nose.

Occlude both nares until bleeding has subsided. Ensure that patient is in upright position. Document epistaxis in patient's medical record.

A client with chronic anemia has received multiple transfusions. About which of the following would the nurse be concerned relative to effects on the client's condition? Over-the-counter iron supplements 60 grams of protein each day Daily multiple vitamin pill Elimination of alcohol

Over-the-counter iron supplements *

PICO question

Population Intervention Comparison Outcome

The physician orders 20 mEq of potassium chloride to be added to the IV solution of a client in diabetic ketoacidosis. The nurse is aware that the reason for this is which of the following? Treatment of hypercapnia Replacement of electrolyte deficit Prevention of flaccid paralysis during rehydration Treatment of cardiac dysrhythmias

Prevention of flaccid paralysis during rehydration

QSEN

Quality and Safety Education for Nurses

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? (Select all that apply.) Quality improvement Research Decision Analysis Financial reimbursement Market Cost Analysis Predictive outcome documentation

Quality improvement Research Decision Analysis Financial reimbursement

The nurse is caring for a client with a PICC line that requires flushing. The nurse has not previously performed this skill. What is the most appropriate action by the nurse to ensure safe care? Attempt to flush the PICC line in the same fashion as a peripheral line. Contact the nurse educator for the unit to help guide the nurse through the skill. Defer the flushing to a more experienced nurse on the oncoming shift. Request a different client assignment and arrange a session on the care of a PICC line.

Request a different client assignment and arrange a session on the care of a PICC line.

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment? signs of kidney suppression with enlargement of the kidneys, reduced urine flow, and concentrated urine signs of abdominal distension, auscultation of reduced bowel sounds, and tympany upon percussion signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes signs of metabolic alkalosis with disorientation because of loss of intestinal fluids

Signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

A nurse is assessing a patient receiving tube feedings and suspects dumping syndrome. Which of the following would lead the nurse to suspect this? Select all that apply. Tachycardia Diarrhea Decreased bowel sounds Diaphoresis

Tachycardia Diarrhea Hypertension Diaphoresis

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client rinses around the clean incision site, using gauze squares moistened with normal saline. The client rinses around the clean incision site, using gauze squares moistened with tap water. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.

The client rinses around the clean incision site, using gauze squares moistened with normal saline.

Which choice demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion? Use sterile gloves during the procedure. Use povidone-iodine to clean the inner cannula when it is removed. Monitor the client's temperature after the procedure. Place the client in the semi-Fowler's position.

Use sterile gloves during the procedure. *The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection. Monitoring the client's temperature is not reflected in application of this question. Povidone-iodine destroys new cellular growth, so it is not used on open wounds. The client should be in high Fowler's, not semi-Fowler's position.

A nurse suspects that a patient is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which of the following would support the nurse's suspicions? Select all that apply. Weakness Confusion Shakiness Dry, hot skin Reports of feeling flushed Tachycardia

Weakness Confusion Shakiness Tachycardia

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action? to lubricate the outside of the suction catheter to clear secretions from the tubing

to clear secretions from the tubing *The picture shows a nurse inserting the suction catheter in a container of water. The hole on the catheter is then occluded creating suction. The water is used to clear the catheter and tubing of secretions. The tubing does not need to be primed or lubricated. The catheter removes the secretions but does not loosen them.

The nurse is teaching a wellness class. Which person is at highest risk for colorectal cancer? The client:

who has been treated for Crohn disease for 20 years Clients over age 50 who have a history of inflammatory bowel disease are at risk for colon cancer. The client who smokes is at high risk for lung cancer. Although the exact cause is not always known, other risk factors for colon cancer are a diet high in animal fats, including a large amount of red meat and fatty foods with low fiber, and the presence of colon cancer in a first-generation relative.

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101°F (38.3°C). The client also has a headache and appears flushed. Place the nursing actions in the order in which the nurse should perform them to properly respond to this client's situation. All options must be used. Stop the infusion. Infuse normal saline to keep the vein open obtain a blood culture from the client Send the blood bag and administration set to the blood back

1. Stop the infusion 2. Infuse Normal Saline to keep the vein open 3. Obtain a blood culture from the client 4. Send the blood bag and administration set to the blood bank

A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? Arrange for typing and crossmatching of the client's blood. Start an I.V. infusion of normal saline solution. Measure the client's vital signs. Compare the client's identification wristband with the tag on the unit of blood.

Arrange for typing and crossmatching of the client's blood.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? Measuring the patient's heart rhythm at least every 6 hours Monitoring the patient's level of consciousness each shift Having the patient frequently rate his or her hunger on a 10-point scale Checking the patient's capillary blood glucose levels regularly

Checking the patient's capillary blood glucose levels regularly *TPN has a high dextrose concentration and may raise blood glucose.

The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month, five clients were diagnosed with pressure ulcers. What should the nurse manager do?

Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.

Which of the following are the major roles of nurses working in institutional, community-oriented, or community-based settings? Select all that apply. Problem-solver Leader Researcher Organizer Practitioner Healer

Problem-solver Leader Researcher Organizer Practitioner

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following? Hyponatremia Pulmonary edema

Pulmonary edema *Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia.

Dumping syndrome

Rapid emptying of gastric contents into small intestines. Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia.

An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. The different leukemias all result in a decrease in the production of white blood cells. The different leukemias all involve unregulated proliferation of white blood cells. The different leukemias all involve the development of cancer in the lymphatic system.

The different leukemias all involve unregulated proliferation of white blood cells..

A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client in renal failure partially loses the ability to regulate changes in pH." What is the cause of this partial inability? The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. The kidneys regulate and reabsorb carbonic acid to change and maintain pH. The kidneys buffer acids through electrolyte changes. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize? Determining the client's strengths Establishing a trusting relationship Making clinical inferences Identifying potential health problems

Establishing a trusting relationship

A nurse working in an acute care setting volunteers to participate in a research study. The nurse understands that research findings add to the scientific base of nursing practice. Evidence-based practice (EBP) accomplishes which of the following? Select all that apply. Delineate the health-illness continuum Establish best nursing practices Improve patient outcomes Decrease health care cost Validate nursing diagnosis Provides answers to ethical questions

Establish best nursing practices Improve patient outcomes Decrease health care cost

A nurse is making a home visit for a 2-year-old child with cancer. Nurses' Notes The client has lost 3 lb (1.4 kg) since last week's home visit. Parents note that the client was prescribed three new medications by the oncologist. Parents keep track of all new medications in a notebook. Medications are kept on the counter of the kitchen "so we will remember to give them." Parents report that sometimes the child experiences nausea and vomiting immediately after taking the medication. The child has not had nausea/vomiting in the past 3 days. Which finding(s) from the nurse's home visit requires follow-up with the parents of the client? Parents make note of new medications. Client vomits after medication. Client lost 3 lb (1.4 kg) in 1 week. Medications are kept on kitchen counter. No nausea/vomiting in past 3 days.

Client vomits after medication. Client lost 3 lb (1.4 kg) in 1 week. Medications are kept on kitchen counter. *The nurse making a home visit must pay attention to assessment details, the home environment, and client/family report. A 3-lb (1.4-kg) weight loss in 1 week requires follow-up to ensure nutritional needs are being met. Medications should not be kept on the kitchen counter with a 2-year-old child in the house. This poses a safety risk. Vomiting after medication ingestion suggests that the child may not be getting the full dose of medication. This requires follow-up. Keeping track of medications and new information regarding a medical diagnosis is important. The parents should be encouraged to continue this practice. It is important to note that nausea/vomiting has improved in the last few days, but this finding does not require follow-up.

A group of nursing students are reviewing information about the older adult and mobility. The students demonstrate a need for additional study when they identify which of the following? An older adult experiences numerous factors that increase the risk for falls. Falls are the leading cause of death due to injury in individuals who are over the age of 75 years.

Falls are the leading cause of death due to injury in individuals who are over the age of 75 years. For people over the age of 65 years, falls are the leading cause of injury leading to death, with hip fractures resulting in significant morbidity and mortality. Numerous factors place the older adult at risk for falls, including a history of falls, fear of falling, cognitive and mood impairments, dizziness, and functional impairments and environmental hazards. Older adults are faced with dealing with the fear of falling and striving for independence. Medications often play a major role in contributing to falls and other complications in the older adult

A nurse working in the intensive care unit (ICU) refers to the Institute for Healthcare Improvement (IHI) Ventilator Bundle prior to planning patient care. The nurse realizes nursing interventions outlined in the bundle will improve patients' outcomes. Which of the following statement best describes how IHI-established nursing interventions should be included in each bundle? Nurse case managers serving as patient advocates recommended nursing interventions to be included in the IHI bundles based on patient preference Best practice derived from valid and reliable research studies guided nursing interventions being added to the IHI bundles

Best practice derived from valid and reliable research studies guided nursing interventions being added to the IHI bundles *Bundles include evidence-based practices. Hospitals, physicians, and nurses work collaboratively to provide care directed by bundles. Nurses advocate on behalf of the patient. Effective time management is a key element in the provision of care, however; IHI-based bundles on evidence-based practice.

As a nurse is aspirating the contents during a tube feeding, the nurse finds that the tube is clogged. What would be appropriate nursing interventions in this situation? (Select all that apply.) Ensure that adequate flushing is completed after each feeding. If necessary, replace the tube. Use a stylet to unclog the tube. Flush with a carbonated beverage such as a cola soft drink. Use warm water and gentle pressure to remove clog. Administer an antiemetic to the patient.

Ensure that adequate flushing is completed after each feeding. If necessary, replace the tube. Use warm water and gentle pressure to remove clog.

When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement? "I know it's very important to wash my hands after irrigating the catheter." "I won't remove the dressing until I return to the clinic next week." "I will monitor my temperature every other day." "My spouse will change the dressing three times a week, using sterile technique."

"My spouse will change the dressing three times a week, using sterile technique."

Derrick is the nurse manager for the psychiatric unit. There are major conflicts between the day and night shift staff. Derrick suggests that each shift put aside their differences for a time and determine a common major goal. Which of the following conflict resolution styles does Derrick display? Avoiding Collaborating

Collaborating *With collaborating there is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. With avoiding there is awareness of the conflict situation but the parties involved decide to either ignore the conflict or avoid/postpone its resolution. Competing is an approach that results in a win for one party at the expense of the other. Smoothing is an effort to complement the other party and focus on agreement rather than disagreement thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

Which of the following is true about a malignant tumor? Gains access to the blood and lymphatic channels Demonstrates cells that are well differentiated Is usually slow growing Grows by expansion

Gains access to the blood and lymphatic channels *By gaining access to blood and lymphatic channels, the tumor metastasizes to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rate of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.

The physician orders a transfusion with packed red blood cells (RBCs) for a patient hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction? Stay with the patient during the first 15 minutes of the transfusion Premedicate the patient with acetaminophen (Tylenol) Administer the blood as soon as it arrives Verify the patient identification according to hospital policy

Verify the patient identification according to hospital policy

You are caring for a patient who had a percutaneous endoscopic gastrostomy (PEG) tube inserted earlier in the day. Which of the following interventions should you plan to perform? Select all that apply. Avoid placing tension on the feeding tube. Administer prescribed analgesics, as needed. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. Place a dressing between the skin and external bumper. Measure the length of exposed tube and compare it with the length documented after insertion. Gently rotate the external bumper 90 degrees once during the shift.

Avoid placing tension on the feeding tube. Administer prescribed analgesics, as needed. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. Place a dressing between the skin and external bumper. Measure the length of exposed tube and compare it with the length documented after insertion.

When checking the placement of a gastrostomy or jejunostomy tube, the nurse must make regular comparisons of: Gastric fluid Air pressure pH Tube length

Tube length

BMI (body mass index)

Underweight - Less than 18.5 Normal - 18.5 - 24.9 Overweight - 25 - 29.9 Obese - 30 - 39.9

How should the nurse place the ear of an adult when using the otoscope?

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