Comprehensive Funds Review

A nurse is performing a straight urinary catheterization for a female client who has urinary retention, which of the following actions indicates the nurse is maintaining sterile technique?

Wipes the labia minora in an anteroposterior direction

a nurse is assessing a clients readiness to learn about insulin self 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 assessing a client who has an onset of severe back pain of unknown origin, which of the following questions should then nurse ask to encourage discussion w/ the client?

"What do you think caused the onset of your pain?"

a nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery, which of the following responses should the nurse make?

"What worries you about being without your teeth?"

a nurse is caring for a client who just rcvd a diagnosis of cancer. the client states "i just don't know what I'm going to do now" which of the following responses should the nurse make?

"can you explain the concerns you're having right now?"

a nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? SATA

- assist client w/ a partial bed bad - measure clients BP after the nurse administers an antihypertensive med - use a communication board to ask what the client wants for lunch

a nurse is caring for a client who has TB, which of the following actions should the nurse take? SATA

- place a client in a room w/ negative pressure air flow - wear gloves when assisting the client w/ oral care - use antimicrobial sanitizer for hand hygiene -N95 mask not surgical mask!

a nurse is performing an abdominal assessment for an adult client, identify the correct sequence of steps for this assessment

1. inspection 2. auscultation 3. percussion 4. palpation

a nurse in a long term care facility is caring for a client who dies during the nurses shift, identify the sequence in which the nurse should perform the following steps

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash clients body 4. ask the clients family members if they would like to view the body 5. place name tag on the body

HCO3 expected range

22-26mEq/L

after assessing a client the nurse documents +1 pedal edema bilaterally this indicates that the nurse observed an indentation of which of the following depths after applying pressure?

2mm

how many ml is required for the open irrigation technique in clients indwelling urinary catheter?

30-40ml of irrigation fluid

PaCO2 expected reference range

35-45 mm Hg

what is the average number of WBC a pt should have

4,000-11,000 microliters

when should elderly pts receive a shingles vaccine

60 years old

pH expected reference range

7.35-7.45

A nurse is planning care for a group of clients who are receiving oxygen therapy, which of the following client should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather Explanation: Nurse should frequently check the bag on a rebreather mask to ensure it inflates properly, if bag is deflated the client will rebreathe his own exhaled CO2 instead of receiving prescribed O2

A nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix, the clients surgical wound is healing by secondary intention, which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin Explanation: May indicate underlying infection

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? A. leave the bag in place fr 45mins B. fill the bag 2/3 full w/ ice C. place the ice bag uncovered on the clients ankle D. tell the pt numbness is expected when the ice bag is in place

B. fill the bag 2/3 full w/ ice explanation: filling the bag only 2/3 full allows the bag to be molded around clients ankle to reduce risk of injury to the clients skin the nurse should leave the ice bag in place for no longer than 30mins towel should be placed on skin to prevent injury the nurse should remove the ice bag if the client feels numbness since this is an indication that the clients skin is too cold and at risk for injury

a nurse discovers that a client received the wrong med which of the following actions should the nurse take first? A. complete a med error report B. notify the prescribing provider C. assess the client D. notify the charge nurse

C. assess the client

A nurse is assisting a client who is eating at mealtime, the client grabs her neck w/ both hands and appears frightened, which of the following actions should the nurse take first?

Determine whether the client is able to breathe

A nurse is replacing the surgical dressings on a client who had abdominal surgery, which of the following actions should the nurse take?

Don clean gloves to remove the old dressing

A nurse is caring for a client who has an NG tube for intermittent enteral feedings, which of the following actions should the nurse take?

Elevate the clients head of bed 45 degrees before the feeding

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention, which of the following information should the nurse include in the teaching ?

Granulation tissue fills the wound during healing Explanation: red tissue called granulation tissue fills the wound during healing, the wound is left open to drain and heal by secondary intention that should occur within 5-21 days, open wounds place the client at an increased risk for wound infection

Secondary intention

Healing when a wound is left open, no sutures or other materials are used to close the wound, dressings are applied instead in order to protect the wound from contamination

A nurse is changing the bed linens for a client who is on bed rest, which of the following actions should the nurse plan to take?

Hold linens away from the body and clothing

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure, which of the following actions should the nurse take?

Insert the tip of the tubing 8cm (3.1in)

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision, which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea, which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag

A nurse is caring for a client who has a history of dysrhythmias, upon entering the room the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless,which of the following actions should the nurse take first?

Start chest compressions

A nurse is caring for a client who is receiving an IV fluid replacement, which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut (tight) skin around the IV catheter site that is cool to the touch

a nurse is planning care for a client who reports abdominal pan, an assessment by the nurse reveals the client has a temp of 39.2C(102.6F) heart rate 105/min a soft nontender abdomen and menses overdue by 2 days. which of the following findings should be the nurses priority?

Temp

A nurse is preparing to administer an intramuscular infection to a client who is overweight, which of the following sites should the nurse select for the injection?

The side hip between the iliac crest and anterior iliac spine

A nurse is planning to administer pain meds to a client who has pain following abdominal surgery, which of the following actions should the nurse take first?

Use the pain scale to determine the clients pain level (get vitals is not the first thing you do annoying)

A nurse is planning care for a client who has a wound infection following abdominal surgery, to promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the clients diet?

Vitamin C and zinc

A nurse is planning care for an adult client who has fluid volume excess, which of the following interventions should the nurse plan to include to monitor the pt's weight?

Weigh the client on arising Explanation: On arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments, and on the same carefully calibrated scale (balanced to 0 before each use)

a nurse is caring for a client who has a sodium level of 125 meq/L which of the following findings should the nurse expect?

abdominal cramping, weakness, confusion, lethargy, headache, and nausea

a nurse is caring for a client who is postoperative and has paralytic ileus, which of the following abdominal assessments should the nurse expect?

absent bowel sounds w/ distention

a nurse is caring for a child who is postoperative following a tonsillectomy, which of the following actions should the nurse take?

administer analgesics to the child on a routine schedule throughout the day and night

a nurse in a medical unit is caring for a client who has difficulty sleeping which of the following actions should the nurse take to promote the clients ability to fall asleep?

allow the client to maintain the same bedtime routine as at home

a nurse has just inserted a NG tube for a client, which of the following findings should the nurse expect to confirm correct tube placement?

an x-ray shows the end of the tube above the pylorus

when should elderly receive an eye exam?

annually

a nurse is caring for a client who reports not sleeping at night which interferes with her ability to function during the day. which of the following interventions should the nurse suggest to the client?

avoid beverages that contain caffeine

a nurse is caring for a client who has an indwelling urinary catheter, which of the following findings indicates that the catheter requires irrigation?

bladder scan shows 525ml of urine rationale: pt with an indwelling urinary catheter should have a continuous urine flow w/o accumulation of urine in the bladder; therefore the nurse should irrigate the catheter to resolve any existing blockage

a nurse is caring for a client who is receiving total parenteral nutrition (TPN) which of the following actions should the nurse take?

check the clients capillary blood glucose level every 4hrs explanation: pt is at risk of hyperglycemia while receiving TPN, the dextrose concentration in TPN increases the risk of this complication

a nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. which of the following actions should the nurse perform immediately following the transfer?

check the patients vital signs explanation: the greatest risk to the client is an injury from unstable vital signs after receiving anesthesia and meds

a nurse is administering !L of 0.9% sodium chloride toa client who is postoperative and has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease in heart rate

"does the pain radiate?"

determines pain location

"is your pain sharp, dull, crushing, throbbing, aching, burning, electric like, or shooting?"

determines quality of pain

what position should a client be in for catheter irrigation

dorsal or supine recumbent positing for maximal access to the catheter

a nurse is preparing to administer eye drops to a client following surgery which of the following actions should the nurse take when instilling eye drops?

drop the eye med into the lower conjunctival sac explanation: you drop it into the lower conjunctival sac to avoid placing the drops on the cornea and causing damage

a nurse is admitting a client who has rubella, which of the following types of transmission based precautions should the nurse initiate?

droplet

while admitting a client to the medical unit, the nurse asks him if he has advanced directives the client states "I have a document w/ me that names someone who can make healthcare decisions for me if i am not able" the nurse should identify that the client is referring to which of the following documents

durable power of attorney doc

a nurse is admitting a client who is having an exacerbation of heart failure, in planning the clients care when should the nurse initiate discharge planning?

during the admission process

a nurse is assessing a client who is experiencing stress/anxiety regarding a recent diagnosis which of the following findings should the nurse expect?

increased BP

a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon who tells the nurse to continue to measure the clients vital signs every 15mins and to report back in 1hr, which of the following actions should the nurse take next?

notify the nursing manager

a charge nurse is observing a newly licensed nurse perform tracheostomy care for a pt, which of the following actions by the newly licensed nurse requires intervention?

obtaining cotton balls for the tracheostomy care explanation: cotton ball particles can be aspirated into the tach opening, possibly causing tracheal abscess.

Role ambiguity

occurs when people are unclear about the expectations of their role in a given situation.

a nurse is collecting health history data from a client who is deaf and uses American sign language (ASL) to communicate, the nurse will be working w/ an ASL interpreter which of the following actions should the nurse take when working w/ the interpreter?

pace speech to allow time for the interpreter to convey the words

a nurse is obtaining the BP in a clients lower extremity, which of the following actions should the nurse take?

place the bladder of the cuff over the posterior aspect of the thigh

a nurse is reviewing a clients fluid and electrolyte status which of the following findings should the nurse report to the provider

potassium 5.4 meq/l

a nurse is preparing to perform mouth care for an unresponsive client which of the following actions should the nurse plan to take?

raise the level of the bed

a nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. which of the following actions should the nurse take while the client is in restraints?

remove the restraints one at a time

a nurse is providing teaching to an older adult client who has constipation, which of the following statements should the nurse include in the teaching?

sit on the toiled 30 minutes after eating a meal

a nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter, which of the following actions should the nurse take?

subtract the amount of irrigation used from the clients urine output

Sick role refers to..

the expectations placed on the individual who has the alteration in health, rather than the caregiver.

a nurse is planning an educational program for a group of older adults at a senior living center, which of the following recommendations should the nurse include?

you should receive a pneumococcal vaccine when you are 65 years old

a nurse is caring for an adult client who communicates an unmet spiritual need which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?

"God is punishing me for something"

A nurse is caring for a client who is post operative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads "clear liquids; advance diet as tolerated" which of the following responses should the nurse make?

"I Am going to listen to your abdomen" Explanation: A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis, the nurse should auscultate the clients abdomen to determine the presence of bowel sounds before clear liquids can be administered

a nurse is discussing the use of herbal supplements for health promotion with a client, which of the following clinical statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immunes system"

a nurse is caring for a client who requires a 24hr urine collection which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7am and have saved all urine since" rationale: for a 24 hr urine collection, the client should discard the first voiding and save all other urine output

a nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer, which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery"

a nurse is teaching a group o older adults about expected changes of aging, which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as i get older."

a nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion, the client expresses concern about the risk of acquiring an infection from the blood transfusion. which of the following statements should the nurse make to the client ?

"donate autologous blood before the surgery." explanation: autologous blood transfusion is the collection and reinfusion of the clients blood, blood is drawn from pt 3-5 weeks before surgery and stored for transfusion at the time of the surgery

a nurse is teaching an assistive personnel about proper hand hygiene, which of the following statements by the AP indicates an understanding of the teaching ?

"there are times I should use soap and water rather than alcohol-based hand rub to clean my hands"

a nurse manager is preparing to review med documentation with a group of newly licensed nurses which of the following statements should the nurse manager plan to include in the teaching?

"use complete name of the med magnesium sulfate"

if a pt has pneumonia/fever and difficulty breathing you should

- place client on droplet precaution - apply oxygen at 2L/min via nasal cannula - request antipyretic med - remain 1m (3 ft) from pt

signs of fluid volume deficits include:

- slow cap refill - weak, thready pulse - hypotension

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perinatal area, which of the following actions should the nurse take first?

Check the clients perineum

A nurse is caring for a client who is postoperative and who has an in dwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2hr which of the following action should the nurse take first?

Check to determine if the catheter tubing is kinked

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a UTI, the client has an indwelling catheter in place, which of the following actions should the nurse take?

Clamp the tubing below the collection port Explanation: Doing this will allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup

A nurse is providing teaching to a client who has a new colostomy about proper care, which of the following info should the nurse include in the teaching?

Cleanse the skin around the stoma w/ warm water (Nurse should instruct pt to Chang epoch every 3-7 days to avoid skin breakdown around stoma, according to ATI)

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evaluator in place, which of the following actions should the nurse take to ensure proper operation of the device?

Collapse the device of air after emptying Explanation: The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity, which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen upon arising in the morning

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when hold the eyelids open

A nurse is caring for a client who has a hearing impairment, which of the following interventions should the nurse use when speaking w/ the client?

Face the client when speaking

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer, which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached

serosanguineous drainage

Made up of RBC's and plasma, is an expected finding in a postoperative wound healing by secondary intention

A nurse is caring for an older adult client who has dysphagia following cerebrovascular accident, which of the following actions should the nurse take when assisting the client at mealtime?

Off the client tart or sour foods first Explanation: The pt who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps w/ chewing and swallowing (its not feed them and drink liquid before swallowing)

A nurse is performing suctioning for a client who has a tracheostomy, which of the following actions should the nurse take?

Pull suction catheter back 1cm (0.5in) if the client starts coughing Explanation: Nurse should do this when pt starts to cough or resistance is met, this will remove the catheter from the mucosal wall of the trachea prior to suctioning

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy, the nurse observes yellow,, thick drainage on the dressing, the nurse should document,meant this finding as which of the following types of drainage?

Purulent exudate Explanation: Purulent exudate drainage on the clients dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection

A nurse is helping a client change his hospital gown, the client has an IV fusion on an infusion pump, which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints, which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restrains within 24hrs

A nurse is applying antiembolitic stockings for a pt who has a history of DVT, which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying

a nurse asks a client to explain the statement, "a bird in the hand is worth two in the bush" through this question, the nurse is evaluating the clients ability in which of the following intellectual functions?

abstract reasoning

a nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dl which of the following actions should the nurse take?

administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion

a nurse is caring for a client who is postoperative, when the nurse prepares to change the clients dressing they say "every time you change my bandage it hurts so much" which of the following interventions is the nurses priority action?

administer pain med 45min before changing the clients dressing

a nurse on a surgical unit is receiving a client who had abdominal surgery from the post-anesthesia care unit which of the following assessments should the nurse make first?

airway

"is your pain constant or intermittent? "

asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain

a nurse is caring for a client who is having difficulty breathing, the client is supine and is receiving supplemental O2 via a nasal cannula, which of the following interventions should the nurse take first?

assist the client to an upright position

a nurse is planning weight loss strategies for a group of clients who are obese which of the following actions by the nurse will improve the clients commitment to a long-term goal of weight loss?

attempt to increase the clients self-motivation

a nurse is beginning her shift and reviewing the MAR for her clients. she notes a dosage of a med above the safe range and sees that a nurse administered that dosage during the previous shift, which of the following actions should the nurse take?

call the provider to clarify the dosage explanation: after assessing the client for adverse effects of the med, the nurse should notify the provider about her observations to determine the next step

valerian and chamomile

can be taken to reduce anxiety

8-10 months

can crawl on hands and knees

8-10 month old

can pull up to a standing position

6-8 months

can sit up without support

5 month old

can turn from abdomen to back

a nurse is performing a home safety assessment for a client who is receiving supplemental O2, which of the following observations should the nurse identify as proper safety protocol?

client identifies the location of a fire extinguisher (client should also use a cotton blanket instead of wool to avoid generating static electricity that could ignite O2)

a nurse is caring for a client who has a terminal illness which of the following findings indicates that the clients death is imminent?

cold extremities explanation: first in the feet and then in the hands, is a physical change that occurs

a nurse is admitting a new client, which of the following actions should the nurse take while performing med reconciliation?

compare the clients home meds w/ the providers prescriptions

a charge nurse is teaching adult CPR to a group of newly licensed nurses, which of the following actions should the charge nurse teach as the first response in CPR?

confirm unresponsiveness

a nurse is measuring vital signs for a client and notices an irregularity in the pulse, which of the following actions should the nurse take?

count the apical pulse rate for 1 full minute and describe the rhythm in the chart

a nurse is caring for a client who is unstable and has vital signs measured every 15mins by an electronic BP machine, the nurse notices the machine begins to measure the BP at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

disconnect the machine, and measure the BP manually every 15mins

a nurse is assessing a client who received an IV fluid bolus for dehydration, which of the following findings should the nurse identify as an indication of fluid volume excess?

distended neck veins

a nurse is caring for a client who has an NG tube for intermittent enteral feedings which of the following actions should the nurse take?

elevate the head of the bed to 45 degrees before the feeding

a nurse is teaching an assistive personnel how to obtain a capillary finger stick blood sample. which of the following actions by the AP requires the nurse to intervene?

elevating the finger above heart level explanation: holding the finger below the level of the heart in a dependent position, will help increase blood flow to the area and ensure an adequate specimen for collection

a nurse is caring for a client who has a terminal illness the client asks several questions about the nurses religious beliefs related to death and dying. which of the following actions should the nurse take?

encourage the client to express thoughts about death and dying

a nurse is assessing four adult clients, which of the following physical assessment techniques should the nurse use?

ensure the bladder of the BP cuff surrounds 80% of the clients arm

a nurse is admitting a client who has decreased circulation in his left leg, which of the following actions should the nurse take first?

evaluate pedal pulses

when do elderly need a tetanus booster?

every 10 years

a nurse is assessing a newborn at birth who was delivered at 32 weeks gestation, which of the following findings should the nurse anticipate?

extended extremities

a nurse is performing a physical assessment of a client, the nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?

faint pedal pulses explanation: this can indicate poor circulation and tissue perfusion

a nurse is planning an in-service training session about nutrition. which of the following statements should the nurse include in the teaching?

fats provide energy explanation: fat serves as a stored energy source for the body providing 9 cal/g of energy

proteolytic enzyme

for unstageable pressure ulcers this type of dressing is applied to facilitate debridement and to soften eschar

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

a charge nurse is discussing the responsibility of nurses caring for a client who has C diff 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 about lifestyle changes to manage a chronic illness, which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes

help the client identify ways that these changes will result in positive personal outcomes

a nurse is caring for a client who has a stage II pressure ulcer which of the following wound dressings should the nurse apply to the ulcer?

hydrocolloid

a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury, which of the following types of dressing should the nurse use?

hydrocolloid rationale: creates a moist wound bed

a nurse is caring for a client who requires a chest x-ray, prior to the client being transported for the procedure, which of the following actions should the nurse take first?

identify the client using two identifiers

a nurse is performing a breast examination for a female client which of the following techniques should the nurse use first?

inspect both breasts simultaneously explanation: according to evidence based practice, the nurse should first inspect both breast w/ the clients arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling

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

What is leukopenia?

it occurs when there is a decrease in the production of WBCs this alteration places the client at an increased risk of infection

a nurse is caring for a client who has a temperature of 38.7C (101.7F) which of the following actions should the nurse take?

keep the clients bed linens dry

a nurse is reviewing a clients lab results and notes a WBC count of 3,600/mm^3 the nurse should identify this result as which of the following conditions

leukopenia

a nurse is receiving a client from the PACU who is postoperative following abdominal surgery, which of the following actions should the nurse take to transfer the client from stretcher to bed?

lock the wheels on the bed and stretcher

A nurse is preparing to insert an indwelling urinary catheter for a male client, which of the following locations should the nurse secure the urinary catheter tubing?

lower abdomen

a nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant which of the following precautions should the nurse plan for this client?

make sure the client wears a mask when outside their room if there is construction in the area

a nurse is preparing to administer a med to a client that has gout, the nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. which of the following interventions is the nurses priority?

measure the clients apical pulse explanation: atenolol is a beta blocker and can decrease the clients heart rate

collagen

nurse should apply collagen to a clean moist wound to stop bleeding bring cells into the wound, and stimulate their proliferation to facilitate healing

during the insertion of a urinary catheter for a client the tip of the catheter brushes against the nurses arm which of the following actions should the nurse take?

obtain a new catheter and reattempt insertion

clicking sounds

occurs in clients who have undergone prosthetic valve replacement surgery

a nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse w/ inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole w/ the diaphragm of the stethoscope positioned at the left sternal border. which of the following heart sounds should the nurse document ?

pericardial friction rub

a nurse is assessing the heart sounds of a client who has developed chest pain that worsens w/ inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole w/ the diaphragm of the stethoscope positioned at the left sternal border. which of the following heart sounds should the nurse document?

pericardial friction rub explanation: this rub has a high pitched scratching, grating, or squeaking leathery sound that is heard best w/ the diaphragm of the stethoscope at the left sternal border

a nurse is employing a thorough, systematic method while obtaining objective data about a client through which of the following methods should the nurse collect this information?

physical examination explanation: physical findings are objective and the nurse should collect this info in a systematic way

a nurse on a rehabilitation unit is preparing to transfer a pt who is unable to walk from a bed to a wheelchair, which of the following techniques should the nurse use?

place the wheelchair at a 45 degree angle to the bed explanation: this will allow the client to pivot, lessening the amount of rotation required

grandiose delusion

pt believes in personal superiority compared to others

reference delusion

pt believes that occurrences in environment are about or because of personal actions

persecutory delusion

pt believes that someone or something wants to intentionally harm them

role overload

refers to having more responsibilities within a role than one person can manage.

a nurse is reviewing the correct use of a fire extinguisher w/ a client which of the following actions should the nurse direct the client to take first?

remove the safety pin from the extinguisher

a nurse is reviewing a clients lab report, the clients ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3-24 mEq/L. the nurse should determine that the client has which of the following acid-base imbalances?

respiratory alkalosis

a community health nurse is preparing a campaign about seasonal influenza, which of the following plans should the nurse include as a secondary prevention ?

screening groups of older adults in nursing care facilities for early influenza manifestations explanation: secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe

respite care

service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance

calcium alginate

should be used for a stage IV pressure ulcer, this dressing is for wounds w/ significant exudate and must be covered with a secondary dressing

a nurse is reviewing the lab data of a client who has a fever and watery diarrhea which of the following results should the nurse report to the provider

sodium 150 mEq/L explanation: this Na level is greater than the expected reference range of 135-145mEq/L the pt is at risk for dehydration due to diarrhea. hypernatremia is a manifestation of dehydration and the nurse should report this finding to the provider

a nurse is caring for a client who has schizophrenia. Patient states "my internal organs have turned to stone" the nurse should document this finding as which of the following types of delusions?

somatic rationale: these pt's believe that a body part is no longer functioning in a realistic or expected manner

transparent dressing is for

stage 1 pressure injuries by preventing further friction and shearing

alginate dressing is for

stage 3/4 pressure injuries to absorb drainage, forms a soft gel when it comes in contact w/ drainage

gauze dressing is for

stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair, to prevent self-injury which of the following actions should the nurse take when lifting the object?

stand close to the cabinet when lifting it, bend at knees, w/ feet wide apart

Ginkgo Biloba (herbal med)

taken to improve memory and reduce stress

feverfew herbal supplement

taken to proport wound healing and decrease inflammation associated with arthritis

ginger

taken to relieve nausea and vomiting and aid in digestion

a nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. which of the following statements should the nurse make?

tell me what i can do to help you overcome your fear of giving yourself injections

a nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection, which of the following routes should the nurse use to obtain the temp?

temporal

a nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis, which of the following statements indicates a lack of readiness to learn by the client ?

the client reports severe pain explanation: a client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity

a nurse is providing teaching to a client w/ heart failure about reducing his daily intake of sodium, which of the following factors is the most important in determining the clients ability to learn new dietary habits?

the involvement of the client in planning the change

a nurse on a medical-surgical unit is washing her hands prior to assisting w/ a surgical procedure, which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

the nurse washes w/ her hands held higher than her elbows explanation: so that waster and soapsuds can drain away from the clean area toward the dirty area

a nurse is witnessing a client sign an informed consent form for surgery, which of the following describes what the nurse is affirming by this action?

the signature on the preoperative consent form is the clients

"what would you rate your pain on a scale of 0 to 10?"

this determines intensity of the pain

Hydrocolloid

this type of dressing is applied to things like a stage II pressure ulcer due to its ability to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin

a nurse observes an assistive personnel preparing to obtain BP w/ a regular-sized cuff for a client who is obese which of the following explanations should the nurse give the AP?

using a cuff that is too small will result in an inaccurately high reading

a nurse is caring for a client who has diarrhea due to shigella, which of the following precautions should the nurse implement for this client ?

wear a gown when caring for the client

a client is being discharged home w/ oxygen therapy delivered through a nasal cannula which of the following instructions should the nurse provide to the client/ family members ?

wear cotton clothing to avoid static electricity

Role conflict

when a person must assume multiple roles that have opposing expectations.

a nurse in a surgical suite notes documentation on a clients medical record that they have a latex allergy. in preparation for the clients procedure which of the following precautions should the nurse take?

wrap monitoring cords w/ stockinette and tape them in place