final 183

What should the nurse confirm as two identifiers? Select all that apply.BirthdateMedical record numberNameSocial Security numberHome address

Birthdate Medical record number Name

John and Martha are on vacation and John is unable to perform sexually as he normally does. He's quite concerned and sees his healthcare provider when the problem continues at home. What statement from his healthcare provider is most accurate?"Maybe you are not as aroused by your wife as you used to be.""It's probably the change of environment causing the problem.""It's a common problem of aging. I know some things we can try that will help.""You were probably exhausted from the long flight."

"It's a common problem of aging. I know some things we can try that will help."

John retired from work last month after 38 years with the same corporation. He's been looking forward to retirement at the age of 65, but is concerned that the days are beginning to wear on him. Physically he does "okay." His hypertension is under control with medications and he runs 2 miles three mornings a week. He is planning a trip overseas this summer with Martha, his wife of 43 years.John has noticed that his knees feel stiff and painful in the mornings as he gets out of bed, so he decides to give up his morning run. What suggestion would be best for John?"Joint pain is common at this age, but biking is less impactful on the joints.""Take pain medicines daily when you wake up to make the run less uncomfortable.""Seek medical attention; you may have an injury.""Consider running at bedtime so the pain will be less intense."

"Joint pain is common at this age, but biking is less impactful on the joints."

Which chart entry would be part of SOAP documentation? Select all that apply. 1.. The client complains of pain at the incision site.2. Redness and edema is noted at the incision site.3. The client was discharged home in stable condition.4. The physician was notified about signs of infection at the incision site.5. The physician performed rounds, visiting the client in the morning.

1,2,4

Identify V. Role Confusion

Age 12-18/20 yearsStage 5Know who you are OR try to do what others expect of you

An informatics nurse is training a group of students on the advantages of using an EHR. What could be some supporting reasons? Select all that apply.

-Can be used by several team members simultaneously-Less repetition of data-Faster-More accurate reporting

The nurse understands that the electronic health record (EHR) has which advantages over paper charting? Select all that apply.

-Facilitates evidence-based nursing practice-Promotes efficient use of the nurse's documentation time-Ensures improved client safety and outcomes

Nursing documentation should be which of the following? Select all that apply.

-Nonjudgmental-Accurate- Specific

Which abbreviations are on The Joint Commission's "do not use" list?

-U or u- IU-MS for magnesium sulfate-Q.D. for daily- Q.O.D.- Lack of leading zero (.X mg)

What is the purpose of documentation?

-improving the facility's care quality-facilitating communication among team members-creating legal report of care delivery-providing consistent care from shift to shift

Which are common documentation guidelines for nurses?

-use chronological order-document throughout the shift-document after each observation

Trust V. Mistrust

0-18 months of ageduring which infants gain trust of their parents or caregivers if their world is planned, organized, and routine.

A client presents to the emergency room after sustaining an injury where a nail entered the hand. Which questions should the nurse ask the client to determine if a tetanus shot is needed? Select all that apply.1. "Do you have any allergies to tetanus toxin?"2. "Have you had a tetanus shot in the past 2 years?"3. "Was the nail rusty or was it brand new out of the box?"4. "Have you sustained a puncture wound like this before?"5. "Can you tell me your current pain level on a scale of 1 to 10?"

1. "Do you have any allergies to tetanus toxin?"3. "Was the nail rusty or was it brand new out of the box?"

A client has been brought in from a motorcycle accident in which he or she has suffered deep track-like injuries with debris that can only partially be removed. What type of dressing should be applied to this client's wounds?1. Alginate2. Absorbent3. Antimicrobial4. Collagen

1. Alginate Alginates facilitate autolytic debridement and are ideal for wounds that are deep, track-like, or tunnel-like.

What are primary causes of maceration? Select all that apply.1. Fever2. Incontinence3. Bowel incontinence4. Infection5. Tanning

1. Fever2. Incontinence

Which are examples of appropriate medication orders for an inpatient? Select all that apply.1. Lasix by mouth twice daily.2. Aspirin 325 mg by mouth every morning.3. Tylenol 500 mg prn.4. Rocephin 200 mg IV q6h.5. Ibuprofen 200 mg q4h prn fever or mild pain.

2,4

Which tissue found in the wound bed is described as dry, thick, and leathery, and may be black, brown, or gray?1. Slough2. Eschar3. Granulation4. Nongranulating

2. Eschar

Which is a method of providing a comprehensive communication during a hand-off report?1. SOAP2. SBAR3. CPOE4. MAR

2. SBARRationale: Situation, background, assessment, and recommendation (SBAR) is an effective communication tool that can be customized for hand-off communication.Test-Taking Tip: Oral reporting is provided to maintain continuity of care and ensure complete transfer of information during hand-off. The report should be restricted to client-focused information and can be done in a variety of formats, with SBAR being recognized as the most effective.

The nurse is documenting wound progress for a client and notes that there is pearly pink tissue in the wound bed as well as granulation tissue. It has decreased in size over the past 4 weeks. Which type of healing should the nurse document is occurring?1. Primary intention2. Secondary intention3. Tertiary intention4. Inflammatory phase

2. Secondary intention This wound is healing by secondary intention, as there is granulation and epithelial tissue in the wound bed. The wound is healing from the inside out.

The nurse examines a wound on a client's hip and notes purulent drainage. The wound culture report states it has developed critical colonization. How should the nurse interpret these findings?1. The wound culture was contaminated.2. The bacteria have overwhelmed body defenses.3. The microorganisms are causing harm and releasing toxins.4. The report means there are microorganisms in the wound.

2. The bacteria have overwhelmed body defenses. Critical colonization means the wound has overwhelming bacterial presence that leads to changes in drainage, color, or odor.

The nurse is preparing a new skin care protocol for elderly residents in a nursing home. Which factors require specialized skin care for these clients? Select all that apply. 1.Changed estrogen levels 2.Decreases in lean body mass 3.Impaired thermoregulation 4.Thinning subcutaneous tissue layer 5.Diminishing sweat and sebaceous glands

2.Decreases in lean body mass4.Thinning subcutaneous tissue layer5.Diminishing sweat and sebaceous glands

Intimacy V. Isolation

Age 18-25/30 years6th stage in Erikson's modelyoung adults must form close, satisfying relationships or suffer loneliness

A nurse notices a wound that has developed on the lower back of a client that has adipose tissue exposed with full-thickness skin loss. What stage is this pressure injury? 1. 1 2. 2 3. 3 4. 4

3. 3

What is the significance of using standardized reporting formats?1. It is required by The Joint Commission.2. It is the policy of most facilities.3. Many serious errors occur as a result of miscommunication between caregivers.4. Physicians expect this practice among nurses.

3. Many serious errors occur as a result of miscommunication between caregivers.

Generativity vs. Stagnation

Age 30-65middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service

Industry V. Inferiority

Age 6-12 yearselementary school - learn the pleasures of applying themselves to tasks, or they fell inferior

Which phase of wound healing describes collagen fibers breaking down and remodeling?1. Hemostasis2. Inflammation3. Granulation4. Epithelialization

4. Epithelialization In epithelialization, collagen fibers are broken down and remodeled.

A client presents to the clinic after falling in a parking lot and sustaining an injury. There is a break in the skin with jagged edges. There is no evidence of foreign debris in the wound. As the nurse documents the wound care, which term would the nurse use in the health record?1. Abscess2. Incision3. Crushing4. Laceration

4. Laceration A laceration is a cut in the skin when the skin and mucous membranes are torn open. It leaves a cut with jagged edges.

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record?1. Serous2. Purulent3. Sanguineous4. Serosanguineous

4. Serosanguineous Serosanguineous drainage is a mixture of serous and sanguineous drainage that is light red or pink-tinged.

Integrity V. Despair

Age 65-Death8th stage in Erikson's modelwhen reflecting at the end of life, an older adult must feel a sense of satisfaction or experience despair (feelings of having wasted one's life)

What roles does the nurse have in transitional care programs? (Select all that apply.)A. Directing patient care in the inpatient settingB. Coaching the patient after dischargeC. Managing chronic conditions after dischargeD. Directing patient care in the clinic settingE. Assessing the patient's risk for readmission

B. Coaching the patient after dischargeC. Managing chronic conditions after dischargeE. Assessing the patient's risk for readmission

John has taken the same blood pressure medication at the same dosage for 10 years. At his last routine physical, his blood pressure was higher than normal. Which statement best describes the reason for this change?His medication was outdated and therefore less potent.He was anxious when his blood pressure was taken.The blood pressure was not taken correctly.Vessels develop increased peripheral resistance with age, causing a rise in blood pressure. Vessels develop increased peripheral resistance with age, causing a rise in blood pressure.Rationale:The increase of peripheral resistance and rise in systolic blood pressure are expected parts of aging. Additionally, cardiac output tends to decrease. As a result of these physiological changes, John should continue a healthy lifestyle, but may also need to increase medications for better outcomes. Throughout the day, John has to urinate every 2 to 3 hours. Although it's onl

An enlarged prostate gland

Tertiary intention

An example of wound healing by tertiary intention would occur after secondary intention. When a secondary intention wound heals enough, it can be surgically closed by tertiary intention.

A nurse is preparing oral medications. A client is concerned that the blood pressure pill is a different color than the one he or she takes at home. How should the nurse respond? A. Return the medication to the pharmacy, as it the wrong medication B. Reassure the client that this is what the doctor prescribed C. Check the label and dosage and confirm that the medication and dosage is correct. Reassure the client that this is a different manufacturer D. Ask the client to bring his medications from home and he can take those

C

The nurse is flushing a client's peripherally inserted central catheter (PICC). What action should the nurse perform first?

Cap the infusion line.

Which of the following is the cause of cataracts?Increased IOPClouding of the lensRetinal detachmentAbrasion on eye surface

Clouding of the lens

Which of the following nursing care may be necessary for older adults as they age? Select all that apply. Community resources Multidrug prescriptions Support for change Long-term care Family therapy

Community resourcesSupport for changeLong-term care

During the administration of a metered-dose inhaler, when should the nurse instruct the client to rinse her mouth? Select all that apply.An hour after the dose has been administeredDirectly after the dose has been administered for certain medicinesDuring the administration of the doseDirectly before the dose is administeredAn hour before the dose is administered

Directly after the dose has been administered for certain medicines Directly before the dose is administered

Which phase of wound healing describes collagen fibers breaking down and remodeling? 1.Hemostasis 2.Inflammation 3.Granulation 4.Epithelialization

Epithelialization Hemostasis includes platelet aggregation.In inflammation, macrophages begin engulfing bacteria and clearing debris.In granulation, fibroblasts migrate to the wound where they form collagen.

The nurse is flushing a client's peripherally inserted central catheter (PICC) to maintain patency, because it is being used intermittently. After flushing with normal saline, which action should the nurse perform next?

Flush the line with heparin.

Which condition is associated with increased intraocular pressure?GlaucomaUveitisMacular degenerationMeniere's disease

Glaucoma

Which of the following terms indicate infection of the eye? Select all that apply.AmblyopiaExophthalmosKeratitisConjunctivitisStye

Keratitis Conjunctivitis

As Cynthia talks to Mrs. Steinhart about the medications to be delivered, what information should the nurse share? Select all that apply.Name of medicationReason for medicationPharmacokinetics of the medicationWho ordered the medicationDose of medication

Name of medication Reason for medication Who ordered the medication Dose of medication

Marjorie is an 80-year-old female. After a car accident 3 years ago, she lost her driver's license because of her poor vision. Her husband died shortly afterward and she could no longer care for herself. Her daughter placed her in an assisted living facility that provides meals and 24-hour supervision and care.Marjorie tells the nurse that she feels "worthless" and wants to become more active. What would be the nurse's best suggestion?Walk around the block three times a day.Participate in chair aerobics in the recreational center.Lift weights in the gym after meals.Take dancing lessons at the city dance hall.

Participate in chair aerobics in the recreational center.

Which are examples of the "rights of medication" administration? Select all that apply.Right clientRight doseRight timeRight route

Right client Right room Right nurse Right dose Right time Right route

Which factors are included in the six rights of medication administration? Select all that apply.Right roomRight locationRight medicationRight routeRight patient

Right location Right medication Right route

Serous drainage

Serous drainage is a clear or a straw-colored fluid; it does not contain pink or red color.

A nurse is teaching about isotonic IV infusions. Which statement indicates a need for further teaching?a."Patients with mild dehydration are prescribed isotonic infusions." b. "Isotonic infusions are indicated in the management of hypernatremia." c."Isotonic solutions will cause no movement of fluid into or out of the cells." d. "The osmolality of isotonic solution ranges between 250 and 375 mOsm/L." breference page 157

b. "Isotonic infusions are indicated in the management of hypernatremia."

Sanguineous drainage

bloody drainage from capillaries No pink

The nurse monitors for which preventable complica- tion in a patient hospitalized for treatment of obesity?A. HyperventilationB. TachycardiaC. Skin breakdownD. Hypertension

c

Speech therapist

diagnose and treat communication and swallowing disorders in patients

Physician

diagnose and treat disease and injuries, provides preventative care, prescribes medications, does surgery

Dietician

evaluates the nutritional status of patients, works with family members and health care team to determine appropriate nutritional goals and dietary regimens

incision

formed from a surgical procedure

Primary intention

healing occurs when the edges are well approximated and heals with minimal scarring. A surgical incision would be healing with primary intention.

Assessing the insertion site of a client's peripherally inserted central catheter (PICC), the nurse notes redness, swelling, and odor at the site. Which complication does the nurse suspect?

infection

laceration

is a cut in the skin when the skin and mucous membranes are torn open. It leaves a cut with jagged edges.

abscess

localized collection of pus. The abscess does not have jagged edges.

Serosanguineous drainage

mixture of serum and red blood cells Looks pink

What is another name for nearsightedness?Amblyopia Hyperopia Presbyopia Myopia

myopia

evisceration

protrusion of viscera through an incision

A Pt. complains of being lightheaded and having difficulty breathing. The nurse notes the Pt. is becoming increasingly confused and anxious, has a weak thready pulse and is wheezing.a) speed shockb) fluid overloadc) septicemiad) air embolism

d) air embolism

A patient is complaining about ringing in their ear and you look over their med-list to see what could be the cause... What medication do you expect to see?

A loop diuretic, such as furosemide (Lasix). An adverse effect of furosemide is ototoxicity.

Which statement by a newly hired health care team member indicates the need for additional education regarding droplet precautions?"A negative-pressure room should be used for droplet precautions.""I Don't need an N95 respirator for droplet precautions.""I need to wear a mask for a patient in droplet precautions.""Droplets can transmit disease longer because they stay in the air longer."

"A negative-pressure room should be used for droplet precautions."

Which statement by a newly hired health care team member indicates the need for additional teaching regarding isolation precautions?"I don't need gloves for droplet precautions. That's only with contact.""We should place the patient with influenza on droplet precautions.""Reusable equipment must be sanitized before use on another patient.""I'll use a disposable stethoscope for the patient in contact precautions."

"I don't need gloves for droplet precautions. That's only with contact."

A patient is placed on droplet precautions. You know his wife needs more teaching about what PPE to use when she says.

"I don't need to wear a mask if I stay a foot away from him"

The preoperative nurse is admitting a patient for same-day surgery. What is the nurse's priority action?Teach the patient how to use an incentive spirometerAssess the patient's vital signsComplete the preoperative checklistStart a large bore intravenous line

Complete the preoperative checklist

A pressure injury with full-thickness skin and tissue loss with deep tissue necrosis of muscle, Fascia, tendon, joint capsule, and bone1. Stage 2 pressure Injury2. Stage 4 Pressure injury3. Unstageable pressure injury

2. Stage 4 Pressure injuryAs in stage 3 injury, there may be tunneling and undermining

Which types of fluid solutions would result in fluid shifting within the body? Select all that apply.

Hypertonic- Hypotonic- Colloid- Crystalloid

The nurse is caring for a patient in the post anesthesia care unit (PACU). What is the nurses priority responsibility for the patient while in this unit? a.Monitoring urine output b.Maintaining a patent airway c.Administering pain medication d.Assessing readiness for discharge

.ANS:B Ensuring a patent airway is the highest priority. A. C. D. These actions will be performed by the PACU nurse and are not the highest priority.

A client has been receiving parenteral therapy while in the hospital. As a result of fluid administration, fluid shifting is noted with the cells of the body becoming more edematous. Which type of fluid would the nurse anticipate being responsible for cellular swelling?

Hypotonic solution

Which is most appropriate to teach the family of the child with sickle cell disease (SCD) about preventing infections?a) get the flu vaccine every 3 yearsb) have TB skin testing every 2 yearsc) get a pneumococcal vaccine every 2 yearsd) inspect cuts, sores, and insect bites carefully

d) inspect cuts, sores, and insect bites carefully

Which item of PPE is donned first?maskeye protectiongowngloves

gown

Erythema of intact skin that will not blanch when touched; usually over a bony prominence1. Stage 1 pressure injury2. Stage 2 pressure injury3. Stage 3 pressure injury

1. Stage 1 pressure injuryIt will not turn blanched or white when you gently touch it with your fingertip. In darker skinned individual, the skin may appear darkened rather than red.

A pressure injury with partial-thickness loss and exposed dermis1. Stage 2 Pressure injury2. Unstageable Pressure injury3. Deep Tissue Pressure injury

1. Stage 2 Pressure injuryThis includes intact, serum-filled blisters and broken blisters that reveal a shallow, pink or red ulceration that is moist. Generally there is erythema surrounding the skin break. The erythematous area may feel warmer than the surrounding skin because of the increased blood flow. Subcutaneous tissue is not visible.

What causes fluid shift from osmotic pressure? Select all that apply.

- Albumin- Hypertonic fluids- Hypotonic fluids- Mannitol

What conditions cause fluid volume excess? Select all that apply

- Cirrhosis- Adrenal gland disorder- Heart failure

Which findings could lead to the presence of edema? Select all that apply.

- Decreased oncotic pressure- Decreased albumin

Which lab values are impacted by fluid volume deficit? Select all that apply.

- Hemoglobin and hematocrit- Urine specific gravity- Sodium- Serum osmolality

The nurse is planning to witness an adult patients consent for a knee arthroscopy. What should the nurse confirm before witnessing the consent? a.Which is the operative knee b.Who is driving the patient home c.What type of job the patient has d.When the patient last ate or drank.

.ANS:A It is essential as part of ensuring that the consent is correct that the nurse verify the surgical procedure and correct site, especially right or left, are correctly written on the consent. B. C. D. This information is not necessary to know before witnessing a patient sign a consent form.

The nurse recommends early ambulation as ordered to be included in the plan of care for a patient recovering from surgery. Which adverse effect is the nurse planning to prevent by early ambulation? a.Coughing b.Thrombophlebitis c.Increased peristalsis d.Impaired wound healing

.ANS:B B. Early postoperative ambulation helps prevent thrombosis. C. Peristalsis should increase to prevent the development of an ileus. A. The patient should be encouraged to cough to prevent respiratory problems. D. Wound healing is not directly aided by early ambulation

The nurse is staging the pressure injury.The assessment of the open but shallow injury with a reddish pink wound bed on the upper side indicates a ________________ pressure injury.The boggy area with visible bone and tendon indicates a_____________ pressure injury

1. Stage 22. Stage 4

The nurse is assisting in the surgical holding area. When should the nurse administer a prophylactic antibiotic to a patient? a.During surgery b.1 hour prior to surgery c.4 hours prior to surgery d.Within the first 2 hours postoperatively

.ANS:B Studies have shown that preventing surgical site infections include giving prophylactic antibiotics within 1 hour prior to surgery (which means the actual incision time). A. The antibiotic is to be given before the surgery begins. C. This period of time is too long before the surgery begins. D. An antibiotic given after the surgery would not be a prophylactic dose

The nurse is contributing to the preoperative patients plan of care. Which patient statement should alert the nurse to plan interventions to help prevent postoperative complications? a.I am 60 years old and in good health. b.This is my second surgery in 2 years. c.I have chronic obstructive pulmonary disease. d.I have not had anything to eat or drink for 8 hours.

.ANS:C The patient with chronic obstructive pulmonary disease could develop respiratory complications after surgery. This patient would benefit from learning deep breathing and coughing and how to use an incentive spirometer. A. B. D. These statements would not cause the patient to develop postoperative complications.

What is the nurse's first action when admitting a client experiencing night sweats and rust-colored sputum to the hospital?1. Place the client in a private room.2. Prepare client for chest x-ray.3. Perform PPD (purified protein derivative) skin test.4. Fit the client for an N95 mask respirator.

1

the nurse applies this mask (N95) before entering a patient's room. What is the name of this mask?1. N952. Isolation mask3. Simple mask4. Body fluid mask

1

The nurse is documenting the appearance of the base of a pressure injury during a dressing change. How would the nurse document the presence of pinkish red tissue at the base of the wound?1 Granulation2. Eschar3. Slough4. Abrasion

1 Granulation

An 80-year-old female patient is transferred to the medical-surgical unit after suffering a stroke in the nursing home. Use the chart to answer the questions. The chart may update as the scenario progresses.The nurse reviews the patient's record. Drag the risk factors that predispose the patient to developing pressure injury to the box on the right. Be sure to drag all that apply.1 Older age2 History of diabetes3 Limited mobility4 Garbled speech5 Weak cough6 NPO status7 Incontinent of

1 Older age2 History of diabetes3 Limited mobility6 NPO status7 Incontinent of urine

The nurse has orders to apply a hydrocolloid dressing to the patient's coccyx. The nurse places the patient comfortably on her side, supporting her with pillows. Drag the five steps the nurse should take to the box on the right to apply the dressing. Arrange the steps in the proper order.

1 perform hand hygiene and don gloves2 Clean the wound if ordered3 Cut the corners of the dressing so they are rounded4 Peel the paper backing from the hydrocolloid dressing5 Place the dressing over the wound and smooth gently

Two nurses are moving a patient up in bed with a draw sheet. In which order would the nurses perform this skill?

1)Lower the head of the bed to as flat a position as the patient can tolerate; remove the pillow from under the patient's head and position it vertically next to the headboard. (2) Roll the draw sheet up until it is close to the patient's body. (3) Grasp the draw sheet near the patient's shoulders and hips. (4) Instruct the patient to bend their knees and place their feet flat on the bed. (5) Tell the patient to push against the bed with their feet on the count of three. (6) On the count of three, shift weight from the back foot to the front foot while lifting the patient with the draw sheet and moving the patient up in bed.

A patient who smokes cigarettes asks the nurse what could be done to stop smoking. What should the nurse recommend to the patient? Select all that apply.1. Medications can be used to reduce cravings.2. Prepare to gain weight after quitting smoking.3. Hypnosis reduces the body's need for nicotine.4. Nicotine replacements help withdrawal symptoms.5. Tapering the number of cigarettes is the best approach.

1, 4

Which movement of fluids and solutes requires energy?1. Active transport2. Osmosis3. Diffusion4. Filtration

1. Active transport

What happens to pH when there is full compensation?1. The pH returns to normal.2. The pH becomes acidotic.3. The pH becomes alkalotic.4. The pH does not move in compensation.

1. The pH returns to normal.(for the body to return to the homeostasis the pH must be in the normal range)

A client has been brought in from a motorcycle accident in which he or she has suffered deep track-like injuries with debris that can only partially be removed. What type of dressing should be applied to this client's wounds?1.Alginate 2.Absorbent 3.Antimicrobial 4.Collagen

1. AlginateAlginates facilitate autolytic debridement and are ideal for wounds that are deep, track-like, or tunnel-like.Absorbent dressings are used to manage drainage.Antimicrobial dressings should be reserved for wounds that contain exudate and are infected.Collagen dressings are used when promotion of collagen fibers and granulation is needed.

Which are types of reactions clients may have to administration of blood and blood products? Select all that apply.1. Allergic2. Hypotensive3. Fluid volume overload4. Febrile5. Decreased urine output6. Thrombus[

1. Allergic(can occur to blood and blood products)3. Fluid volume overload(occur when administering blood and blood products to a client)4. Febrile

Which factors should the nurse consider prior to selecting a vein for an intravenous (IV) catheter insertion? Select all that apply.1. Client's age2. Client's gender3. Type of solution4. Speed of infusion5. Length of hospital stay

1. Client's age(age of the client should be considered prior to selecting a vein. Older and younger clients have more fragile veins and smaller IV catheters should be used)3. Type of solution(larger vein should be chosen for blood transfusion and medications with low pH)4. Speed of infusion(larger veins should be selected for fluids that need to infuse at a faster rate. This prevents damage to smaller veins)

While preparing a client's medications, a nurse notices that the client has a penicillin allergy, and the doctor has ordered penicillin. What are the next appropriate actions?1. Do not give the medication. Contact the provider for clarification.2. Call the pharmacy and see what the pharmacist thinks should be done.3. Give the medication as ordered. The provider is aware of the medical history.4. Call the pharmacy to substitute another antibiotic.

1. Do not give the medication. Contact the provider for clarification.

Symptoms of dehydration1. Dry skin2. Thirst3. Decreased urine output4. Increased heart rate5. Increased blood pressure6. Hypothermia7. Orthostatic hypotension8. Protruding neck veins

1. Dry skin2. Thirst3. Decreased urine output4. Increased heart rate5. Increased blood pressure7. Orthostatic hypotension

The nurse is concerned that a client is in uncompensated respiratory acidosis. Which are possible reasons why the body is not compensating? Select all that apply.1. Excess sedation medication2. Brain injury from a bleed3. Blockage of the airway4. Kidney failure5. Dehydration

1. Excess sedation medication2. Brain injury from a bleed3. Blockage of the airway

Symptoms of fluid overload1. Hypertension2. Tachycardia3. Reddened, warm skin4. Jugular venous distention (JVD)5. Bounding pulses6. Tachypnea7. Weight loss8. Sunken eyes

1. Hypertension2. Tachycardia4. Jugular venous distention (JVD)5. Bounding pulses6. Tachypnea

The nurse is caring for a client in metabolic acidosis. With this condition, the nurse would anticipate which arterial blood gas changes? Select all that apply.1. Increase in CO22. Increase in HCO33. Decrease in HCO34. Increase in pH5. Decrease in pH

1. Increase in CO23. Decrease in HCO35. Decrease in pH

Which are complications of IV therapy? Select all that apply.1. Infiltration2. Infection3. Blood loss4. Allergic reaction5. Thrombus

1. Infiltration(occurs when IV solution leaks out of the vessel and into surrounding tissues)2. Infection(can occur in insertion sites if the site is not kept clean)5. Thrombus(small clot that dislodges in a vein as a result of the IV catheter)

Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply.1. Irregular wound edges2. Wound bed beefy red3. Periwound area reddened4. Pain noted with ambulation5. Loss of hair to the periwound area

1. Irregular wound edges2. Wound bed beefy red3. Periwound area reddened

A client with impaired renal function is in diabetic ketoacidosis. What acid-base imbalance would be anticipated?1. Metabolic acidosis2. Respiratory alkalosis3. Respiratory acidosis4. Metabolic alkalosis

1. Metabolic acidosis

What are some advantages to computerized safety methods in medication administration? Select all that apply.1. Monitor for safe dosing2. Perform medication calculations3. Alert for errors4. Confirm compatibilities5. Minimize cost

1. Monitor for safe dosing2. Perform medication calculations3. Alert for errors4. Confirm compatibilities

When the carbonic acid portion of the buffering system is out of balance, which of the following occurs? Select all that apply.1. Respiratory Alkalosis2. Metabolic Alkalosis3. Respiratory Acidosis4. Metabolic Acidosis

1. Respiratory Alkalosis(a respiratory disturbance alters the carbonic acid portion of the buffering system and the resulting imbalance is labeled respiratory acidosis or respiratory alkalosis)3. Respiratory Acidosis(a respiratory disturbance alters the carbonic acid portion of the buffering system and the resulting imbalance is labeled respiratory acidosis or respiratory alkalosis)

Which acid-base imbalance is present when a client's ABG shows a pH of 7.27, PCO2 of 55, and HCO3 of 24?1. Respiratory acidosis2. Respiratory alkalosis3. Metabolic acidosis4. Metabolic alkalosis

1. Respiratory acidosis(is indicated by a low pH, high PCO2, and normal HCO3)[WRONG]2. Respiratory alkalosis(alkalosis is reflected by a pH of over 7.45)3. Metabolic acidosis(HCO3 is normal, which shows the acidosis is not metabolic)4. Metabolic alkalosis(the condition described is not metabolic or alkalosis)

The nurse is caring for a client with asthma and pneumonia who is hyperventilating. Which acid-base imbalance would be anticipated?1. Respiratory alkalosis2. Metabolic acidosis3. Respiratory acidosis4. Metabolic alkalosis

1. Respiratory alkalosis

Which lifestyle choices can lead to alterations in skin integrity? Select all that apply.1. Smoking2. Tanning3. Exercise4. Daily bathing5. Adequate nutrition

1. Smoking2. Tanning

Which are examples of electrolytes? Select all that apply.1. Sodium2. Iron3. Potassium4. Oxygen5. Calcium

1. Sodium(develop an electrical charge when dissolved in water)3. Potassium(electrolyte associated with an electrical charge)5. Calcium(has an electrical charge when dissolved in water)

The nurse caring for a patient with chronic leukemia in an acute care setting. The patientasks the nurse to observe the patient's last bowel movement as it is very dark. The nurseimmediately contacts the primary health care provider (HCP). What would explain thenurse's action?1. The patient may have a gastrointestinal bleed.2. The patient may have overdosed on iron supplements.3. The patient is most likely severely dehydrated.4. The patient is ready for discharge to home.

1. The patient may have a gastrointestinal bleed.

Which describe symptoms of dehydration? Select all that apply.1. Thirst2. Increased blood pressure3. Rapid pulse4. Muscle fatigue5. Increased respirations

1. Thirst(initial symptom of dehydration)3. Rapid pulse(rapid, weak pulse is associated with dehydration)4. Muscle fatigue(symptom of moderate dehydration)

Which is a sensible fluid loss?1. Urine output2. Perspiration3. Weeping edema4. Moisture in exhalation

1. Urine output

Which are sources of fluid loss in the body? Select all that apply.1. Urine2. Skin3. Lungs4. Spinal cord5. Bone

1. Urine(urine accounts for the greatest amount of fluid loss in the body)2. Skin(fluid is lost through the skin via perspiration and heat)3. Lungs(water is exhaled through each breath)

What type of chronic wound is found typically in the lower extremities and manifests as a shallow wound with irregular wound margins and a wound bed that appears "ruddy" or "beefy" red and granular?1. Venous stasis ulcer2. Arterial ulcer3. Pressure injury4. Diabetic foot ulcer

1. Venous stasis ulcer

Partially Compensated Metabolic Acidosis1. pH < 7.352. pH > 7.453. pH 7.35-7.454. Pco2 < 35 mm Hg5. Pco2 > 45 mm Hg6. HCO3 < 22 mEq/L7. HCO3 > 26 mEq/L8. HCO3 22-26 mEq/L

1. pH < 7.354. Pco2 < 35 mm Hg6. HCO3 < 22 mEq/LIn this situation, the body is in a metabolic acidosis (renal impairment, starvation, diabetic ketoacidosis) and has not compensated enough for the pH to normalize. Compensation in metabolic acidosis would occur with hyperventilation as the body tries to blow off carbon dioxide (acid).

Uncompensated Respiratory Acidosis1. pH < 7.352. pH > 7.453. pH 7.35-7.454. Pco2 < 35 mm Hg5. Pco2 > 45 mm Hg6. HCO3 < 22 mEq/L7. HCO3 > 26 mEq/L8. HCO3 22-26 mEq/L

1. pH < 7.355. Pco2 > 45 mm Hg8. HCO3 22-26 mEq/LIn uncompensated respiratory acidosis, the client should demonstrate an increased respiratory rate in an attempt to compensate for the acidosis. If the client cannot increase the respiration rate (e.g., because of oversedation, brain injury, or airway obstruction) the body will retain more acid, eventually causing cardiac arrest.

Uncompensated Metabolic Acidosis1. pH < 7.352. pH > 7.453. pH 7.35-7.454. Pco2< 35 mm Hg5. Pco2 > 45 mm Hg6. Pco2 35-45 mm Hg7. HCO3 < 22 mEq/L8. HCO3 > 26 mEq/L

1. pH < 7.356. Pco2 35-45 mm Hg7. HCO3 < 22 mEq/LIn uncompensated metabolic acidosis, the client has not begun compensating for the acid-base imbalance. The underlying problem must be corrected before the condition deteriorates.

Partially Compensated Respiratory Acidosis1. pH < 7.352. pH > 7.453. pH 7.35-7.454. Pco2 < 35 mm Hg5. Pco2 > 45 mm Hg6. HCO3 < 22 mEq/L7. HCO3 > 26 mEq/L8. HCO3 22-26 mEq/L

1. pH < 7.357. HCO3 > 26 mEq/L5. Pco2 > 45 mm HgIn partially compensated respiratory acidosis, the client is beginning to compensate for the retention of acid from inadequate ventilation. Aggressive pulmonary toileting is needed to prevention further problems and improve the acid-base imbalance.

What nursing goal should be implemented when a nurse notices eschar on a client's heel? 1.Debride the wound. 2.Cleanse and protect the area. 3.Promote epithelialization. 4.Promote remodeling

1.Debride the wound.

The nurse is educating a client with new onset type 1 diabetes mellitus regarding microvascular and macrovascular complications. Which interventions should the nurse instruct the client to include in daily care to prevent skin breakdown? Select all that apply. 1.Inspect the feet daily. 2.Soak the feet every day .3.Dry the feet thoroughly. 4.Wear well-fitting shoes. 5.Clip the toenails every week

1.Inspect the feet daily. 3.Dry the feet thoroughly .4.Wear well-fitting shoes.

Which findings would the nurse expect to find when performing wound care for a client with a venous stasis ulcer? Select all that apply. 1.Irregular wound edges 2.Wound bed beefy red 3.Periwound area reddened 4.Pain noted with ambulation 5.Loss of hair to the periwound area

1.Irregular wound edges2.Wound bed beefy red3.Periwound area reddened

What type of chronic wound is found typically in the lower extremities and manifests as a shallow wound with irregular wound margins and a wound bed that appears "ruddy" or "beefy" red and granular? 1.Venous stasis ulcer 2.Arterial ulcer 3.Pressure injury 4.Diabetic foot ulcer

1.Venous stasis ulcer

Autonomy V. Shame

18 months-3 yearsErikson's second stage in psychosocial development, in which children achieve a balance between self-determination and control by others

Which of these treatments would the nurse most likely expect to be prescribed for a client who is diagnosed with influenza? Select all that apply.1. Antibiotics within the first 48 hours2. Antivirals within 24 to 48 hours of symptom onset3. Adequate fluid intake to avoid dehydration4. Antipyretics and analgesics for fever and body aches5. Throat swabs before medication

2 3 4

Which electrolyte is often given as a supplement to elderly people to reduce the risk of fractures and osteoporosis?1. Sodium2. Calcium3. Potassium4. Zinc

2. Calcium(provides strength and structure for bones and is given to prevent bone loss)

Which occurs with the hematocrit level in the blood while IV solution is administered?1. Hematocrit increases2. Hematocrit decreases3. Hematocrit remains unchanged4. Depends on the osmolality of the solution

2. Hematocrit decreases(because the blood becomes less concentrated)

The nurse is caring for a client with a hypotonic fluid ordered for infusion. What would be the reason for this type of fluid being used? Select all that apply.1. Intracellular space is swollen.2. Intracellular space is dry.3. Both extracellular and intracellular space is equal.4. Extracellular spaces are dry.5. Extracellular spaces are swollen.

2. Intracellular space is dry.5. Extracellular spaces are swollen.

Which body systems will attempt to keep the body in homeostasis if acid-base imbalance continues for an extended period of time?1. Heart2. Kidneys3. Lungs4. Spleen5. Liver

2. Kidneys(will try to buffer the imbalance if breathing is the problem)3. Lungs(will try to buffer the imbalance by breathing faster and deeper or more shallow and slower)

Acid-base balance is reflected through which arterial blood gas values? Select all that apply.1. PO22. PCO23. pH4. HCO35. HGB

2. PCO2(partial pressure of carbon dioxide (PCO2) is a determinant of acid base balance)3. pH(is the acidity of arterial blood and is a determinant of acid base balance)4. HCO3(bicarbonate is a determinant of acid base balance)

The nurse notes an increase in the fluids removed with gastric suctioning. What electrolyte should be monitored more closely as a result?1. Sodium2. Potassium3. Calcium4. Phosphorus

2. Potassium

Which is the greatest determinant of intracellular osmolality?1. Sodium2. Potassium3. Calcium4. Glucose

2. Potassium(lives inside a cell and is the greatest determinant of intracellular osmolality)

Which are the purposes of administering hypertonic IV solutions? Select all that apply.1. Increase blood volume following trauma.2. Stabilize blood pressure.3. Reduce edema.4. Increase intracranial pressure.5. Increase urine output.

2. Stabilize blood pressure.(hypertonic solution are used to stabilize blood pressure in hypovolemia)3. Reduce edema.(hypertonic solution reduce edema by pulling fluids into the intravascular areas)5. Increase urine output.(hypertonic IV solutions increase urine output)

A pressure injury with full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue but not involving muscle or bone1. Stage 2 pressure injury2. Stage 3 pressure injury3. Stage 4 pressure injury

2. Stage 3 pressure injuryUndermining and tunneling may be seen in this stage.

The nurse initiates a transfusion of packed red blood cells to a client. Ten minutes later, the client develops fever, chills, shortness of breath, and a heart rate of 120 beats per minute. What should be the nurse's first intervention?1. Notify the health-care provider.2. Stop the transfusion immediately.3. Flush the intravenous tubing with 0.9% normal saline.4. Administer an antihistamine to stop the reaction.

2. Stop the transfusion immediately.(immediately discontinue the transfusion and then infuse 0.9% normal saline with new tubing. This would prevent further infusion of contaminated blood into the client)

If a peripheral IV access attempt is unsuccessful, what action should the nurse take?1. Withdraw the needle and attempt to reinsert it.2. Withdraw the needle and attempt IV access using another needle and another site.3. Have a more experienced colleague attempt to reinsert it.4. Leave the needle in the site to anchor the vein and attempt with another needle.

2. Withdraw the needle and attempt IV access using another needle and another site.(should withdraw the needle, apply pressure to the site, and attempt a second site using another needle)

The health-care provider prescribes 0.9% sodium chloride to infuse at 100 mL/hour. The nurse hangs a new 1 liter bag at 0800. The nurse returns to the room at 1200 and notices only 200 mL of the solution has infused. What is the most appropriate intervention for the nurse to perform?1. Increase the rate of infusion to make up the difference.2. Change the prescription to reflect the rate of 50 mL/hour.3. Adjust the rate of infusion to 100 mL/hour and document the intake.4. Notify the health-care provider of the error and document the error in the medical record.

3. Adjust the rate of infusion to 100 mL/hour and document the intake.(the nurse should adjust the rate of infusion to the prescribed rate of 100mL/hour and document the fluid volume that infused)

Upon assessment, the nurse identified a positive Trousseau's sign. What electrolyte is of concern?1. Potassium2. Phosphorus3. Calcium4. Sodium

3. Calcium

Which imbalance would be reflected by the ABG result of pH 7.35, PCO2 38, HCO3 18?1. Uncompensated respiratory acidosis2. Compensated respiratory alkalosis3. Compensated metabolic acidosis4. Uncompensated metabolic alkalosis

3. Compensated metabolic acidosis

Edema is caused by an excess of which type of fluid?1. Intracellular2. Extracellular3. Interstitial4. Transcellular

3. Interstitial(lies between cells and excess interstitial fluid results in edema)

Normal Arterial Blood Gasses1. pH 7.25-7.352. pH 7.30-7.403. pH 7.35-7.454. Pco2 32-49 mm Hg5. Pco2 35-45 mm Hg6. HCO3 18-22 mEq/L7. HCO3 18-28 mEq/L8. HCO3 22-26 mEq/L

3. pH 7.35-7.455. Pco2 35-45 mm Hg8. HCO3 22-26 mEq/LNormal acid-base balance would include each of these parameters

Fully Compensated Metabolic Alkalosis1. pH < 7.352. pH > 7.453. pH 7.35-7.454. Pco2 < 35 mm Hg5. Pco2 > 45 mm Hg6. HCO3 < 22 mEq/L7. HCO3 > 26 mEq/L8. HCO3 22-26 mEq/L

3. pH 7.35-7.455. Pco2 > 45 mm Hg7. HCO3 > 26 mEq/LFully compensated metabolic alkalosis means that the client was in uncompensated metabolic alkalosis (acid loss from vomiting, gastric suction, excessive diuretics) and the body has not compensated by hypoventilation or correcting the underlying problem.

A nurse caring for a client diagnosed with tuberculosis requires further teaching when the charge nurse makes which observation?1. Nurse wears N95 mask during client care.2. Client transported to radiology while wearing a mask.3. Visitors wear snug-fitting surgical masks.4. Client wears mask when visiting family in waiting area.

4

What is the nurse's best action when admitting a client diagnosed with influenza to the hospital?1. Place the client in a semi-private room.2. Avoid placing a mask on the client when in the hallway.3. Start intravenous line and restrict po fluid intake.4. Place the client on droplet precautions.

4

Which imbalance is present with the following ABG values: pH 7.40, PCO2 51, HCO3 34?1. Compensated metabolic acidosis2. Uncompensated metabolic alkalosis3. Uncompensated metabolic acidosis4. Compensated metabolic alkalosis

4. Compensated metabolic alkalosis(the PCO2 and HCO3 are elevated, but the pH is within normal limits, which means this is compensated)

Fully Compensated Respiratory Alkalosis1. Pco2 > 45 mm Hg2. HCO3 > 26 mEq/L3. Pco2 35-45 mm Hg4. pH 7.35 -7.405. pH 7.40-7.456. Pco2 < 35 mm Hg7. HCO3 < 22 mEq/L8. HCO3 22-26 mEq/L

5. pH 7.40-7.456. Pco2 < 35 mm Hg7. HCO3 < 22 mEq/LWith respiratory alkalosis, the client is likely hyperventilating, often from fear or anxiety. In a compensated situation, the kidneys have excreted enough buffer to allow for compensation.

Which intervention should the nurse include in the plan of care to prevent atelectasis in a client with postoperative pain from abdominal surgery?A) Control painB) Assess incisionC) Apply TED hoseD) Administer antibiotics

A

Which nonverbal pain indicator would be a sign of acute pain?A) Dilated pupilsB) Decreased blood pressureC) Slow speechD) Withdrawal

A

The nurse is using a sit-to-stand lift. The nurse is most likely caring for which patients? Select all that apply. A)A frail patientB)A paralyzed patient from the waist downC)A malnourished patientD)An 88 y.o. patientE)A post-operative patient recovering from abdominal surgery

A)A frail patientC)A malnourished patientD)An 88 y.o. patientE)A post-operative patient recovering from abdominal surgery

The nurse is contributing to the plan of care for a patient who is on bedrest. Which cardiovascular interventions should the nurse recommend including in the patient's plan of care? Select all that apply.A)Encourage a range of motion.B)Apply sequential compression devices.C)Use anti-embolism stockings. D)Maintain proper body alignment.E)Place a trochanter roll by the patient's thigh.

A)Encourage a range of motion.B)Apply sequential compression devices.C)Use anti-embolism stockings.

Which are methods of nonpharmacological pain management? Select all that apply.A) Cutaneous stimulationB) AcupunctureC) Application of heat and coldD) ReorientationE) Listening to music

A, B, C, E

Which statement by the nurse indicates an understanding of the benefits of multidisciplinary care? (Select all that apply.)A. "I'm glad the social worker can focus on finding a placement for this patient."B. "I don't have time for this teaching; the nutritionist can go over dietary plans."C. "The occupational therapy evaluation made it clear there are more issues with activities of daily living (ADLs) to resolve before this patient can be discharged."D. "I'm not worried about length of stay. The bean counters can deal with that."E. "Discharge planning is much easier when we talk about it together as a team."

A. "I'm glad the social worker can focus on finding a placement for this patient."C. "The occupational therapy evaluation made it clear there are more issues with activities of daily living (ADLs) to resolve before this patient can be discharged."E. "Discharge planning is much easier when we talk about it together as a team."

The nurse is evaluating this blood gas: pH = 7.30, Pco2 = 29 mm Hg, HCO3- = 16 mEq/L Which terms describe this acid-base imbalance? Select all that apply.A. AcidosisB. AlkalosisC. RespiratoryD. MetabolicE. CompensatedF. Partially CompensatedG. Uncompensated

A. AcidosisD. MetabolicF. Partially CompensatedRationale: This ABG represents metabolic acidosis with partial compensation.

A nurse is caring for a patient with a diagnosis of MI. The patient calls the nurse because he is experiencing chest pain. The nurse administers an SL nitroglycerin tablet as prescribed. After 5 minutes, the chest pain is unrelieved by the nitroglycerin. The next nursing action is which of the following?A. Administer another nitroglycerin tabletB. Increase the flow rate of the oxygenC. Contact the providerD. Call the charge nurse

A. Administer another nitroglycerin tablet

A nursing student is reviewing her note cards for the RAAS. She has renin, angiotensinogen, angiotensin I, and angiotensin II. Which factor should come next?A. AldosteroneB. Antidiuretic hormone (ADH)C. Angiotensin converting enzymeD. Atrial natriuretic peptide (ANP)

A. Aldosterone

Which are complications of intravenous therapy that the nurse needs to monitor for? Select all that apply.A. HematomaB. InfiltrationC. ExtravasationD. PhlebitisE. Thrombophlebitis

A. HematomaRationale: A hematoma is a localized mass of blood outside the blood vessel.B. InfiltrationRationale: Infiltration is the seepage of nonvesicant solution or medication surrounding tissues.C. ExtravasationRationale: Extravasation is the seepage of a vesicant substance into the tissue, causing tissue damage.D. Phlebitis Rationale: Phlebitis is inflammation of the vein.E. ThrombophlebitisRationale: Thrombophlebitis is a thrombosis and inflammation.

Which acid-base imbalance is present when a client's ABG shows a pH of 7.27, a Pco2 of 55, and a HCO3 of 24?A. Respiratory AcidosisB. Respiratory AlkalosisC. Metabolic AcidosisD. Metabolic Alkalosis

A. Respiratory AcidosisRationale: Respiratory acidosis is indicated by a low pH, high Pco2, and normal HCO3.Test-Taking Tip: If an acid-base imbalance is caused by an abnormal Pco2, then it is a respiratory abnormality; if it is caused by an abnormal HCO3, then it is a metabolic imbalance.

When the carbonic acid portion of the buffering system is out of balance, which of the following occurs? Select all that apply.A. Respiratory AlkalosisB. Metabolic AlkalosisC. Respiratory AcidosisD. Metabolic AcidosisE. Compensation

A. Respiratory AlkalosisRationale: A respiratory disturbance alters the carbonic acid portion of the buffering system and the resulting imbalance is labeled respiratory acidosis or respiratory alkalosis.C. Respiratory AcidosisRationale: A respiratory disturbance alters the carbonic acid portion of the buffering system, and the resulting imbalance is labeled respiratory acidosis or respiratory alkalosis. Test-Taking Tip: Carbonic acid is linked to the respirations.

What happens to pH when there is full compensation?A. The pH returns to normalB. The pH becomes acidoticC. The pH becomes alkaloticD. The pH does not move in compensation

A. The pH returns to normalRationale: For the body to return to homeostasis, the pH must be in the normal range.Test-Taking Tip: The pH indicates the state of the body, whether it is acidotic or alkalotic.

A patient recovering from surgery in the post-anesthesia care unit begins to thrash in bed and pull at the endotracheal tube and IV lines. For which health problem should the nurse provide care for this patient? a.Delusions b. Sundowning c.Hallucinations d.Emergency delirium

ANS D Until its effects wear off, anesthesia can alter neurologic function. Patients may arrive in the PACU awake, arousable, or sleeping. Patients who are sleeping should become more alert during their stay in the PACU. As they emerge from anesthesia, they may become agitated or wild acting for a short time; this is called emergence delirium. Once resolved, the patient returns to calm state and has no recollection of the episode. A. B. C. The patient recovering from anesthesia is not experiencing delusions, sundowning, or hallucinations.

While dangling a patient in preparation for ambulation after surgery the abdominal incision suddenly eviscerates. What action should the nurse take after positioning the patient supine with flexed knees? a.Cleanse the abdomen. b.Administer pain medication. c.Apply an abdominal binder securely. d.Apply sterile saline-moistened dressings.

ANS DAfter placing the patient in the low Fowlers position with the knees flexed the nurse should cover the wound with sterile dressings or towels moistened with warm sterile normal saline. Notify the physician immediately of this surgical emergency. Apply gentle pressure over the wound, and keep the patient still and calm. A. The abdomen should not be cleansed. B. Pain medication can be provided after the immediate problem is addressed. C. An abdominal binder should not be applied at this time.

The nurse is collecting data from a patient recovering from epidural anesthetic during surgery. What finding should the nurse make a priority to report? a.Patients blood pressure is 100/60 mm Hg. b.Patient reports a feeling of heaviness in the legs. c.Patient reports a feeling of numbness in the legs. d.Patient experiences chills and shaking postoperatively.

ANS:A Hypotension can result after epidural anesthesia and is caused by sympathetic blockade causing vasodilation which reduces venous return to the heart and therefore reduces cardiac output. This finding must be reported. B. C. As the block wears off, patients feel as if their legs are very heavy and numb. This is normal. D. This is not related to the epidural.

The nurse is caring for a patient who had spinal anesthesia. Which effect from spinal anesthesia may influence the safety of the patient when getting out of bed for the first time after surgery? a.Hypotension b.Hypertension c.Hypoventilation d.Hyperventilation

ANS:A Hypotension results from sympathetic blockade causing vasodilation, which reduces venous return to the heart and therefore reduces cardiac output. Postural hypotension may occur if the patient rises too rapidly, creating a risk for falling. B. C. D. Spinal anesthesia does not cause hypertension, hypo- or hyper-ventilation.

A patient recovering from surgery asks the nurse what types of anesthesia cause a loss of sensation in a specific area of the body while the patient remains alert. Which responses should the nurse give? (Select all that apply.) a.Local anesthesia. b.Spinal anesthesia. c.Topical anesthesia. d.General anesthesia. e.Epidural anesthesia.

ANS:A, B, C, E Local anesthesia causes a loss of sensation in a specific area of the body while the patient remains alert. Epidural and spinal anesthesia are forms of local anesthesia. D. General anesthesia causes a loss of consciousness

The nurse is caring for a patient who had abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.) a.Monitor for unilateral swelling of the calf. b.Monitor first voiding after catheter removal. c.Position carefully and pad bony prominences. d.Encourage use of incentive spirometer as ordered. e.Monitor pain level each hour that patient is awake. f. Assist the patient to change position in bed every 4 hours.

ANS:A, B, D, E Monitoring for calf swelling, voiding after catheter removal, use of incentive spirometer, and pain level are focused on preventing postoperative complications for this patient. C is an intraoperative intervention. F. The patient should move more than every 4 hours.

The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which actions should the nurse recommend be included in the patients plan of care? (Select all that apply.) a.Ambulate the patient tid. b.Apply anti-embolic stockings. c.Massage the patients legs daily. d.Place a pillow under the patients knees. e.Perform leg exercises 10 times hourly while awake.

ANS:A, B, E For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length anti-embolic stockings, and give low molecular weight heparin if ordered. D. It is also important to avoid pressure under the knee from pillows to prevent clot formation. C. Legs should not be massaged, as a clot, if present, could be dislodged and become an embolus

The intraoperative practical/vocational nurse is caring for a patient who is undergoing abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.) a.Encourage leg exercises. b.Assist physician as directed. c.Assist with patient positioning. d.Monitor for unilateral swelling of the calf. e.Participate in a time out before surgery begins. f. Assist the patient to change position in bed every 4 hours.

ANS:A, B, E The surgical (second assistant) technician: assists physician (may be an RN, LPN/LVN, or surgical technologist). Encouraging leg exercises and participating in surgical time out are focused on preventing complications for this patient in surgery. The practical/vocational nurse can participate in positioning as directed. Everyone must participate in the time out. C. D. F. These actions are postoperative interventions for respiratory and circulatory complications, not intraoperative interventions. Also, the patient should move more than every 4 hours

The nurse is caring for a postoperative patient. When getting the patient out of bed for the first time after surgery, which actions should the nurse take to maintain safety? (Select all that apply.) a.Use two people to assist patient. b.Dangle the patient at the bedside. c.Assist the patient to stand in one motion. d.Have the patient stand with no assistance. e.Instruct the patient to place the nurse light on to get up.

ANS:A, B, E When a patient is getting up after surgery for the first time dizziness and weakness may occur. The patient is a fall risk at this time. Ideally, two health care workers should assist the patient to dangle before standing to prevent falls the first time getting up. C. The patient should not stand up in one motion. D. The patient needs assistance to stand.

The nurse is assisting in preparing the patient for surgery. Which surgical consent should the nurse recognize as being a legal consent? (Select all that apply.) a.Consent signed by a 17-year-old for her infants surgery. b.Consent signed by a foster mother for a 17-year-old patient. c.Consent signed by a 28-year-old for his own elective surgery. d.Consent signed by 16-year-old patient for his or her own urgent surgery. e.Consent signed by a 60-year-old patient 1 hour before receiving morphine. f. Consent signed by 36-year-old patient 1 hour after receiving lorazepam (Ativan).

ANS:A, C, E The 60-year-old patient is an adult and no narcotics have been given that may impair judgment, so it is a legal consent. The consent was signed by a 17-year-old who is the childs legal parent. The 28-year- old patient is an adult signing for his own surgery without evidence of impairment. B. It is not known if the foster mother is the legal guardian for the 17-year-old patient. D. The patient is 16 years old and cannot give consent because of being a minor. F. The patient received medication to affect mentation. This consent is not legal.

The nurse works on a preoperative unit. For which conditions should the nurse recognize that urgent surgery is needed? a.Hernia repair b.Fracture repair c.Aortic aneurysm d.Ruptured appendix

ANS:B Urgent surgery is the need for an operation within 24 to 30 hours. C. D. An aortic aneurysm and ruptured appendix require emergency surgery. A. A hernia repair is elective surgery.

The nurse is contributing to the intraoperative plan of care for a patient undergoing an appendectomy. Which statement would be an appropriate intraoperative outcome for this patient? a.Verbalizes fears b.Remains free from injury c.Demonstrates leg exercises d.States understanding of discharge instructions

ANS:BRisk for perioperative-positioning injury related to positioning, chemicals, electrical equipment, and effect of being anesthetized is an intraoperative concern of the nurse and has an outcome of being free from injury. A. C. These are preoperative outcomes. D. This is a postoperative outcome.

The nurse is caring for a patient 23 hours after abdominal surgery. Which finding would require the nurse to take action? a.Report of flatus b.Lack of appetite c.Abdominal distention d.Hypoactive bowel sounds in four quadrants

ANS:C Distention could indicate paralytic ileus which is a postoperative complication. A. B. D. These are normal postoperative findings.

A patient scheduled for surgery is to receive anesthesia that causes a total loss of sensation and a complete loss of consciousness. What term should the nurse use to document this patients type of anesthesia? a.Local anesthesia b.Spinal anesthesia c.General anesthesia d.Epidural anesthesia

ANS:C General anesthesia causes the patient to lose sensation, consciousness, and reflexes. A. B. C. These are all types of local anesthesia that do not cause total loss of sensation and a complete loss of consciousness.

The nurse is assisting a patient recovering from surgery on the use of an incentive spirometer. Which patient instruction is appropriate? a.Do not hold breath after inhaling. b.Exhale five times before inhaling. c.Inhale deeply until the target is reached. d.Exhale deeply until the target is reached

ANS:C Instructions for incentive spirometer use include the following: Sit upright, at 45 degrees minimum, if possible. Take two normal breaths. Place mouthpiece of spirometer in mouth. Inhale deeply until target, designated by spirometer light or rising ball is reached, and hold breath for 3 to 5 seconds. Exhale completely. Perform 10 sets of breaths each hour. A. B. D. These are incorrect instructions when teaching on the use of an incentive spirometer.

The nurse is caring for a patient who has developed an increased temperature during the first 24 hours postoperatively. Which action should the nurse take? a.Restrict oral fluids. b.Give antipyretic medication. c.Encourage coughing and deep breathing. d.Provide passive range of motion exercises.

ANS:C Usually, increased temperature during the first 24 hours postoperatively indicates atelectasis if no other cause exists, so coughing and deep breathing should be encouraged to open the alveoli and prevent pneumonia. D. Range of motion exercises will not affect the temperature. B. Antipyretic medication does not affect the cause. A. Fluids should be encouraged as ordered, as dehydration can increase temperature.

The nurse is witnessing an adult patients surgical consent. What should the nurse confirm before witnessing the surgical consent? (Select all that apply.) a.The patients next of kin b.When the patient last ate or drank c.The last time a sedative was administered d.Whether the patient is informed about the surgery e.If family members have questions related to the surgery

ANS:C, D As the patients advocate, ensure before the consent is signed that the patient is informed about the surgery and has no further questions for the physician. If the patient has questions, the consent should not be signed, and the physician should be contacted to answer the patients questions. The consent cannot be signed if the patient is under the influence of sedatives or narcotics, so timing of their administration must be verified. A. B. E. The nurse does not need to confirm the patients next of kin, when the patient last ingested food or fluids, or if the family members have questions about the surgery

The nurse has reinforced preoperative teaching with a patient about coughing and deep breathing techniques. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.) a.I should avoid deep breathing after surgery. b.I should take shallow breaths after surgery to prevent pain. c.Coughing and deep breathing helps prevent respiratory problems. d.I should cough and deep breathe 10 times every hour while awake. e.I should cough and deep breathe beginning 2 days after my surgery.

ANS:C, D Deep breathing helps prevent the development of atelectasis. Coughing moves secretions to prevent pneumonia. They are done 10 times hourly while the patient is awake for 24 to 48 hours postoperatively. A. These exercises should be done after surgery. B. Shallow breaths are not recommended. E. This exercise should be done up to 2 days after the surgery.

When should the nurse perform hand hygiene?

After changing a wound dressingWhen returning to the nursing unit from lunch After emptying a Foley catheter of urine After changing the sheets of a patient with fecal incontinence

Treatment for a 45-year-old in hypovolemic shock from blood loss after a gunshot wound.

AlbuminRationale: Albumin expands the vascular space and is not contraindicated in bleeding disorders. Mannitol is an osmotic diuretic and will cause additional fluid loss.

The nurse is providing frequent dressing changes to an abdominal wound due to large amounts of drainage. The repeated use of tape is irritating the skin. Which intervention would be the best option for the nurse to use to alleviate the problem?

Apply Montgomery straps.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?

Apply a tourniquet to the client's upper arm.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes.

When completing a routine assessment of a client's peripherally inserted central catheter (PICC), the nurse finds no redness, swelling or drainage at the insertion site. The transparent dressing is dry and intact and adheres to the skin around all edges. What is the most appropriate intervention at this time?

Ask the client about any pain or discomfort at the insertion site.

How would a nurse classify a noninfected wound that was surgically created but has had direct contact with the normal flora of the respiratory, urinary, or gastrointestinal tract?A Clean woundB Clean-contaminated woundC Contaminated woundD Colonized wound

B Clean-contaminated wound

The nurse is evaluating this blood gas: pH = 7.51, Pco2 = 49 mm Hg, HCO3- = 33 mEq/L Which terms describe this acid-base imbalance? Select all that apply.A. AcidosisB. AlkalosisC. RespiratoryD. MetabolicE. CompensatedF. Partially CompensatedG. Uncompensated

B. AlkalosisD. MetabolicF. Partially CompensatedRationale: This ABG represents metabolic alkalosis with partial compensation.

The medical-surgical nurse implements SBAR to promote effectiveness in which aspect of quality and safety in patient care?A. SurveillanceB. CommunicationC. OrganizationD. Cost-effectiveness

B. Communication

A patient with heart failure who takes furosemide [Lasix] is diagnosed with bacterial pneumonia. Which medication, if order by the physician, should the nurse question.A. Ciprofloxacin [Cipro]B. Gentamicin [Geramycin]C. Amoxicillin [Amoxcil]D. Erythromycin [E-Mycin]

B. Gentamicin [Geramycin]This is a ototoxic aminoglycoside antibiotic.

Which body system will attempt to keep the body in homeostasis if acid-base imbalance continues for an extended period of time?A. HeartB. KidneysC. LungsD. SpleenE. Liver

B. KidneysRationale: The kidneys will try to buffer the imbalance if breathing is the problem.C. LungsRationale: The lungs will try to buffer the imbalance by breathing faster and deeper or more shallow and slower.

Acid-base balance is reflected through which arterial blood gas values? Select all that apply.A. Po2B. Pco2C. pHD. HCO3E. HGB

B. Pco2Rationale: The partial pressure of carbon dioxide (Pco2) is a determinant of acid-base balance.C. pHRationale: pH is the acidity of arterial blood and is a determinant of acid-base balance.D. HCO3Rationale: Bicarbonate (HCO2) is a determinant of acid-base balance.

Which assessments should the preoperative nurse obtain prior to surgery? Select all that apply. Blood pressure Pain assessment Insurance authorization White blood cell count Oral temperature

Blood pressurePain assessmentOral temperatureWhite blood cell count

The nurse reassesses the client 30 minutes after administering a narcotic analgesic and notices the client has a respiratory rate of 6 breaths/minute. What should the nurse's first intervention be?A) Perform cardiopulmonary resuscitation.B) Notify the primary healthcare provider.C) Administer a dose of naloxone (Narcan).D) Schedule an immediate breathing treatment.

C

Which action should the nurse take when positioning a patient who has limited mobility? A)Place pillows under the patient's upper arms. B)Elevate the patient's knee with three pillows.C)Pull the patient's lower shoulder just slightly forward. D)Keep the heel firmly positioned against the mattress.

C)Pull the patient's lower shoulder just slightly forward.

The nurse is caring for a client with a compression fracture of the spine with decreased mobility as well as intractable pain. The nurse requests a prescription for compression stockings. The healthcare provider prescribes compression stockings and aspirin 81 mg PO QD. Which factors indicate the need for these? Select all that apply.A) AgeB) OsteoporosisC) Intractable painD) Decreased mobilityE) Compression fracture

C, D

Which imbalance would be reflected by the ABG result of pH 7.35, Pco2 38, HCO3 18?A. Uncompensated Respiratory AcidosisB. Compensated Respiratory AlkalosisC. Compensated Metabolic AcidosisD. Uncompensated Metabolic Alkalosis

C. Compensated metabolic acidosisRationale: A result of pH 7.35, Pco2 38, HCO3 18 reflects compensated metabolic acidosis.Test-Taking TipIf the pH is normal, but one of the other ABG values is abnormal, the body has compensated for the abnormality.

The nurse plans to closely monitor for which clinical manifestation after administering furosemide [Lasix]?A. Decreased pulseB. Decreased temperatureC. Decreased blood pressure D. Decreased respiratory rate

C. Decreased blood pressureHigh-ceiling loop diuretics, such as furosemide, are the most effective diuretic agents. They produce more loss of fluid and electrolytes than any others. A sudden loss of fluid can result in decreased blood pressure

When providing discharge teaching for a patient who has been prescribed furosemide [Lasix], it is most important for the nurse to include which dietary items to prevent adverse effect of furosemide [Lasix] therapy?A. Oranges, spinach, and potatoesB. Baked fish, chicken, and cauliflowerC. Tomato juice, skim milk, and cottage cheeseD. Oatmeal, cabbage, and bran flakes A. Oranges, spinach, potatoesThese foods are rich in potassium. Important to replenish potassium because furosemide can deplete potassium (hypokalemia). A patient is prescribed spirolactone [Aldactone] for treatment of hypertension. Which foods should the nurse teach the patient to avoid?A. Baked fishB. Low-fat milkC. Salt substitutesD. Green beans

C. Salt substitutes

A client reports to the nurse that there is drainage leaking around the Jackson-Pratt (JP) drain. The nurse notices the JP drain bulb is empty and the dressing is saturated with serosanguineous drainage. What should the nurse do first?

Check the JP drain tubing for kinks

Fluid therapy for a 22-year-old female patient who is pregnant and admitted with hyperemesis gravidarum after vomiting for the last seven days.

CrystalloidRationale: Crystalloid therapy would be used in fluid replacement for a pregnant patient with hyperemesis. More specifically, an isotonic solution is indicated initially to restore the vascular volume and followed by a hypotonic solution to rehydrate the cells. Colloid therapy would not be indicated. The use of colloid therapy would be contraindicated because fluid would pull from the extravascular to the intravascular space.

A woman who is undergoing chemotherapy for breast cancer develops a warm, reddened area in her left calf. The nurse gives a Situation, Background, Assessment, Recommendation (SBAR) report to the provider. Which test should the nurse request?Radiography imagingD-dimer testTreadmill testPlethysmography

D-dimer test

Which imbalance is present with the following ABG values: pH 7.40, Pco2 51, HCO3 34?A. Compensated Metabolic AcidosisB. Uncompensated Metabolic AlkalosisC. Uncompensated Metabolic AcidosisD. Compensated Metabolic Alkalosis

D. Compensated Metabolic AlkalosisRationale: The Pco2 and HCO3 are elevated, but the pH is within normal limits, which means this is compensated.Test-Taking Tip: If one or both components of the ABG are abnormal while the pH is normal, the imbalance has been compensated by other body processes.

The nurse questions which order for the patient with cardiomyopathy?A. ACE inhibitorsB. Beta blockersC. DiureticsD. SL nitroglycerin

D. SL nitroglycerin

The nurse is caring for a client whose intravenous infusion ran in quickly over a short amount of time, placing the client in fluid overload. What symptoms should the nurse anticipate? Select all that apply.Elevated blood pressureIncreased pulse strengthIncreased pulse rateSunken eyesReddened, warm skin

Elevated blood pressureIncreased pulse strengthIncreased pulse rate

What is the nurse's highest priority of care during the preoperative phase of care?Teaching to prevent complicationsEnsuring the patient's physiological safetyExplaining the 0-10 pain assessment scaleAsking the patient about support system

Ensuring the patient's physiological safety

Fluid replacement for an 18-year-old male patient with a normal blood pressure, experiencing leg cramps after completing a marathon.

Hypotonic solutionRationale: A hypotonic solution shifts fluid out of the vessels into the cells, which improves the dehydration causing the leg cramps. A hypertonic solution would pull more fluid from the already dry cells.

The nurse is preparing to don personal protective equipment (PPE) before entering a patient's room who is on droplet precautions. The patient needs suctioning. In which sequence would the nurse apply the PPE?

Gown, mask, goggles, and gloves

Clients at risk for hypovolemia

Hiker without water supply, Vomiting from a viral infection, Uterine rupture during childbirth, Significant burns to the body, Motor vehicle accident with traumaHypovolemia, or deficient fluid volume, occurs when there is a proportional loss of fluid and electrolytes from the extracellular fluid. This can be caused by: (1) insufficient intake of fluids (hiker), (2) excessive fluid loss (trauma, rupture, and vomiting), and (3) fluid shifts (burns). Poor myocardial functioning, increased secretion of ADH, and increased release of aldosterone would increase fluid retention.

Symptoms of fluid overload

Hypertension, Tachycardia, Tachypnea, Bounding pulses, Juglar venous distention (JVD)The symptoms of fluid overload in the vascular space include hypertension, bounding pulses with tachycardia, tachypnea with shallow breathing, JVD, and an increase in dilute urine. If the fluids are in the extracellular location, symptoms include edema and cool, pale skin. Weight gain will occur, and the client may have trouble with oxygenation from fluid around the lungs.

Prior to surgery, the nurse is reviewing the client's readiness for surgery. Which observation can be a "show stopper" and requires the surgeon be notified? Select all that apply. Hypertension Use of aspirin Nausea Elevated white blood cells A new cough

HypertensionUse of aspirinElevated white blood cellsA new cough

Fluid replacement for a 28-year-old female with severe hyponatremia and low blood pressure from adrenal insufficiency and a lack of aldosterone.

Hypertonic solutionRationale: A hypertonic solution will increase serum sodium levels while shifting fluid into the circulation and creating vascular expansion, thereby raising the blood pressure. An isotonic solution would not correct the hyponatremia, only the low blood pressure.

During the preoperative period, the nurse would notify the healthcare provider of which of the following assessment findings? Select all that apply.Increased blood pressureNormal sinus rhythm on ECG tracingElevated white blood cell countPatient taking aspirin daily for painFever

Increased blood pressureElevated white blood cell countPatient taking aspirin daily for painFever

Fluid requirement for a 58-year-old male patient admitted with hypokalemia who requires intravenous potassium replacement therapy.

KCL with IV solution

Clients at risk for hypervolemia

Liver failure, Excess salt intake, Excessive IV fluid administration, Poor kidney functioning, Decreased cardiac outputHypervolemia, or fluid volume excess, is a result of excess retention of sodium and water in the extracellular fluid. It can be caused from (1) excessive intake of fluids (IV or orally), (2) inability to excrete fluids (excess salt intake, poor kidney function, and decreased cardiac output), and (3) excess fluids outside the vascular space (liver failure).

Please place in the proper order the sequence of events related to how the RAAS activation causes an increase in blood pressure.-Low blood pressure detected by the kidneys-RAAS activated -Increased blood pressure-Aldosterone released-Increased sodium and water reabsorption by the kidneys-Increased blood volume

Low blood pressure detected by the kidneys-RAAS activated -Aldosterone released-Increased sodium and water reabsorption by the kidneys-Increased blood volume -Increased blood pressure

The nurse in the preoperative area knows that a complete informed consent includes which of the following components? Select all that apply.Name of the surgeon performing surgeryConsent to administer blood productsConsent for anesthesiaExact length of time surgery is to takeDescription of how the surgery will benefit the patient

Name of the surgeon performing surgeryConsent to administer blood productsConsent for anesthesiaDescription of how the surgery will benefit the patient ?

An elderly client who is hypotensive has been admitted to the nursing unit for fluid replacement therapy. What intravenous solution would the nurse expect to administer?

Normal saline

Fluid replacement therapy for an 80-year-old male patient who is hypotensive.

Normal salineRationale: An isotonic fluid would be indicated for replacement therapy for a hypotensive elderly patient to fill the vascular space. Three percent normal saline is a hypertonic solution and would cause fluid shifting and worsen cellular dehydration.

The nurse is re-assessing a patient's abdomen. Which reason is correct as to why the nurse alters the normal order a physical assessment techniques

Palpation of the abdomen before auscultation will alter bowel sounds

The nurse is admitting Alvin for sinus surgery. Alvin tells the nurse "I've been hospitalized 25 times in my 72 years of life." Drag and drop the information the nurse should collect next.

client historyA detailed medical history and assessment is required to ensure a safe and successful surgery. The preoperative nurse is responsible for obtaining and documenting this history on admission.

The nurse is providing care to a patient on contact precautions. The nurse accidentally rips a glove on the side of the bed. Which infection control precaution should the nurse implement?

Remove gloves and wash hands

which gauge catheter is indicated for infusion in an adult patient with fragile veins?a. 18 gaugeb. 20 gaugec. 22 gauged. 24 gauge

d

The nurse assesses a stage 3 pressure ulcer on the coccyx of a client. The nurse notes the wound bed is pink with pink to red drainage without odor. Which type of drainage would the nurse document in the medical record?

Serosanguineous

The nurse receives hand-off report on each of these clients. Who is at the greatest risk for fluid volume excess?The client recovering from a large abdominal surgery.The client with diarrhea for the past three daysThe client with heart failureThe client who's semiconscious and unable to drink water

The client with heart failure

The preoperative nurse needs further instruction from the nurse manager when which action is observed?The nurse places compression stockings on the patient's legs before the procedure.The nurse asks the patient's spouse to witness the surgical consent.The nurse prints current lab results and places a copy on the chart.The nurse tells the patient that early ambulation after surgery is best.

The nurse asks the patient's spouse to witness the surgical consent.

A pt. complains of discomfort at their IV site. The nurse notes swelling, discoloration and resistance when trying a flush.a) phlebitisb) thrombophlebitisc) hematomad) infiltration

c) hematoma

Place in order the steps for obtaining a sterile wound culture.

The nurse would gather the needed supplies and don nonsterile gloves. After removing the old dressing, the nurse would place an emesis basin under the base of the wound and then irrigate the wound using a 35-mL syringe with a 19-gauge angiocatheter. This prevents too much psi that results from using a smaller syringe. The nurse would then twist the top of the aerobic culturette tube to loosen the swab and press the swab against a beefy red portion of the wound bed. The next step is to carefully insert the swab into the aerobic culturette container and then crush the bottom of the ampule to activate the culture medium. The nurse should then label the tube with the name, time, date, and source and send it to the lab.

Nicking the vein during an unsuccessful venipuncture attempt, discontinuing the I.V. cannula or needle without pressure, or applying a tourniquet too tightly above a previously attempted venipuncture site cause?a) phlebitisb) thrombophlebitisc) hematomad) venous spasm

c) hematoma

The nurse is assessing a client after surgery who is dehydrated and experiencing hypotension, tachycardia, and decreased urine output. What additional assessment should the nurse perform?Lung soundsBowel soundsPupillary responseTongue and skin turgor

Tongue and skin turgor

The nurse is removing personal protective equipment (PPE) after irrigating a patient's wound on droplet precautions. Which technique would the nurse use to remove PPE?

Touch the earpieces of the goggles with bare hands to remove

While helping Marjorie with her morning care, the nurse notices several skin tears and bruises on her arms. Marjorie notices the nurse looking at them and says, "My skin used to look smooth and pretty, but now it gets damaged so easily." What steps should the nurse make? Select all that apply.Provide a foam mattress for the bed.Pad the corners of hard objects in the room.Encourage wearing long sleeves.Avoid contact with tape and adhesive bandages.Use gentle soaps and lotions. Provide a foam mattress for the bed.Pad the corners of hard objects in the room.Encourage wearing long sleeves.Avoid contact with tape and adhesive bandages.Use gentle soaps and lotions.Rationale:Because of loss of elasticity and thinning of the skin, the older adult's skin is more prone to tears and bruises. Limiting trauma by providing padding and avoiding tape is helpful. Use of gentle soaps and lotions can improve skin's dryness, a factor th

Use padded briefs

The nurse practitioner is performing an annual physical examination on an 88-year-old female. Which assessments are most important to include? Select all that apply. Breast cancer screening Visual acuity exam Gait and balance Pap test Height and weight

Visual acuity examGait and balanceHeight and weight

Marjorie becomes bedridden after a fall that resulted in a hairline fracture of her pelvis. She begins to develop a cough of yellow sputum and requires higher amounts of oxygen at night to maintain adequate oxygen levels. Which physiological changes of aging contribute to her current condition? Select all that apply. Weakened immune system Decreased muscle strength Decreased cardiac output Decreased skin elasticity Decreased intercostal muscle strength

Weakened immune systemdecreased muscle strengthdecreased skin elasticity

A nurse is planning for the placement of a peripheral IV access. Which statement by the nurse indicates a need for further discussion?a. "The tourniquet should be applied distal to the site of venipuncture."b. "Selection of the catheter will depend on the age of the patient."c. "The tourniquet should be released after venipuncture is completed."d. "Selection of the catheter will depend on the therapy prescribed."

a

which IV infusion necessitates central venous line administration?a. IV fluid pH value of 4.5 b. IV fluid with pH value of 5.5c. IV fluid pH value of 6.5d. IV fluid with pH value of 7.5

a

A health care team member comes to the door of an examination room with a patient in droplet precautions. The team member needs to ask a question of the team member caring for the patient. What, if any, PPE is required for the team member at the door?glovesnoneeye protectiona mask

a mask

The nurse is assessing the insertion site of a client's peripherally inserted central catheter (PICC). What is a normal finding?

a transparent dressing covering the site

The nurse is teaching about the most common causes of death in the patient with sickle cell disease (SCD). What should the nurse include? Select all that apply.a) infectionb) hypertensive crisisc) stroked) organ damagee) obstructive lung disease

a) infectionc) stroked) organ damage

An inflammation of the vein in which the endothelial cells of the venous wall become irritated and cells roughen, allowing platelets to adhere and predispose the vein to inflammation-induced?a) phlebitisb) thrombosisc) catheter embolismd) infiltratio

a) phlebitis

The nurse is reviewing Juan's allergies and documents that he is allergic to penicillin. The nurse then reviews the preoperative medication list to ensure that Juan has not been prescribed a penicillin product. Drag and drop the medication the nurse should question.

cefazolin sodiumCefazolin sodium, a cephalosporin antibiotic, should be questioned by the nurse. A client with a penicillin allergy is also likely to exhibit an allergic reaction to this drug classification.

A nurse who has specialized training in placement of peripherally inserted central catheters (PICCs) is inserting a PICC for a patient in the perioperative phase. Which steps should the nurse follow to prevent any complications? Select all that apply.a. the nurse should confirm placement of the catheter by using ultrasound guidanceb. the nurse should use the larger veins present in upper extremitiesc. the nurse should insert the PICC in the jugular of subclavian vein and the tip of the catheter is advanced into the superior vena cavad. the nurse should use a 10 mL syringe to flush or to administer medication through this cathetere. the nurse should insert the catheter in an emergency situation and should not keep it in for more than 48 hours

abd

Nurse (RN)

accesses clients health status, identifies health problems and develops, coordinated and evaluates care

Initiative V. Guilt

age 3 to 5preschooler - learn to initiate tasks and carry out plans, or they feel guilty about efforts to be independent

Jason is being prepared for knee surgery. The nurse completes the preoperative checklist, health history, and admitting assessment. A latex allergy is noted. Drag and drop the safety action that the nurse should take next

allergy bandThe client requires proper identification of allergies so that an error does not take place during medication administration.

Which is a normal finding upon assessment of a client's peripherally inserted central catheter (PICC)?

an insertion site free of blood and intravenous (IV) solution

respitatory therapist

assess and implements therapeutic measures in the care of clients with respiratory problems

The nurse is assessing a client's peripherally inserted central catheter (PICC) insertion site. The nurse measures the length of the catheter that extends out from the insertion site to:

assess if the catheter has migrated inward or moved outward.

Social worker

assessment of individuals and family psychosocial functioning, provides care to help enhance or restore capacities, this can include locating services and providing counseling

Psychologist

assessment, treatment, and management of mental disorders, psychotherapy with individuals, groups and families

OT

assists clients with impaired function to gain the skills to perform activities of daily living

Unlicensed assistive personnel

assume delegated aspects of basic patient care

A nurse is teaching about isotonic IV infusions. Which statement indicates a need for further teaching?a."Patients with mild dehydration are prescribed isotonic infusions."b. "Isotonic infusions are indicated in the management of hypernatremia."c."Isotonic solutions will cause no movement of fluid into or out of the cells."d. "The osmolality of isotonic solution ranges between 250 and 375 mOsm/L."

b

Which step followed by a nurse while administering TPN IV may help decrease the development of thrombosis?a. decreasing the rate of infusion rapidly when discontinuing the TPNb. infusing the TPN into a central venous access device with the tip placed in the vena cavac. changing the administration set used to infuse TPN every alternate dayd. setting the infusion rate of the TPN at the target rate immediately after starting the infusion

b

Formations resulting from the infiltration of blood into the tissues at the venipuncture site?a) phlebitisb) hematomac) thrombophlebitisd) catheter embolism

b) hematoma

Among the anemias, which symptom is unique to sickle cell disease?a) fatigue, pallor, SOAb) pain and swollen joints and extremitiesc) tachycardia and tachypnead) low hemoglobin and hematocrit levels

b) pain and swollen joints and extremities

A Pt. complains of pain at their IV site. Upon inspection of her Pt.'s IV site, the nurse notes redness, warmth, and a palpable cord along the vein.a) extravasationb) phlebitisc) hematomad) thrombophlebitis

b) phlebitis

Which is the most beneficial instruction that the nurse can teach a patient about preventing a sickle cell crisis?a) refrain from taking too much waterb) refrain from traveling in depressurized airplanesc) perform regular workouts and brisk walkingd) wear tight-fitting clothes

b) refrain from traveling in depressurized airplanes

Which is true regarding sickle cell disease (SCD)? Select all that apply.a) the sickle cell trait is present in one of the parents of the patientb) the patient has some protection against malariac) the patient has RBCs that are extremely malleabled) the RBCs become elongated when exposed to decreased tensione) the life span of RBCs in the patient is 15 to 20 days

b) the patient has some protection against malariad) the RBCs become elongated when exposed to decreased tensione) the life span of RBCs in the patient is 15 to 20 days

A nurse's Pt. has developed a fever, and their IV that has stopped infusing. The nurse is unable to flush her Pt.'s catheter and see's the Pt. has signs of malaise.a) phlebitisb) thrombosisc) local infectiond) infiltration

b) thrombosis

The nurse is caring for a patient taking multiple cardiac medications. The patient asks which medication should be taken during episodes of chest pain. Which medication is correct?a. Aspirinb. Nitroglycerinc. Calcium channel blockerd. Statin

b. Nitroglycerin

The nurse reviews the blood work to confirm that all preventive measures are in place before Joe's scheduled orthopedic surgery. It is possible that he will require blood products during surgery. Drag and drop the additional requirement for blood delivery.

blood consentA signed blood consent is required before surgery. The client should also undergo a type and screen to determine blood type and the presence of antibodies will be used to cross match blood in case the client needs blood during the surgical procedure.

A nurse is caring for a patient who has dehydration and is needing a fluid challenge. Which isotonic IV solution should the nurse request from the primary healthcare provider?a. 0.33% sodium chlorideb. 0.45% sodium chloridec. 0.9% sodium chlorided. 3% sodium chloride

c

Which patient is most likely to be affected by sickle cell disease (SCD)?a) a member of an Indian tribeb) a person of Cuban nationalityc) a person of tropical African descent d) an individual of Middle Eastern origin

c) a person of tropical African descent

The nurse conducts client education based on the information collected during the client history and physical assessment process. The nurse suggests DVT prophylaxis. Drag and drop the medication often given for this.

heparinA surgical client is at risk for the development of deep vein thrombosis (DVT) during the postoperative period. The nurse should include information about preventing DVT during preoperative education, including post-operative prophylaxis.

Melva is scheduled for a heart surgery. The surgeon comes to the preoperative area to review the surgical procedure with her. Alternatives are discussed, along with the benefits and risks associated with the surgery. Melva says she understands everything. Drag and drop the action the nurse should complete next

informed consentInformed consent is when a client autonomously grants permission to a provider to perform a surgical procedure, after understanding and considering all its alternatives, benefits, and risks. Although obtaining consent is the role of the provider, it is the nurse's responsibility to ensure that the client has all information needed to make an informed decision about the procedure. In addition to reviewing the consent form with the client and validating his or her understanding, nurses often serve as the witness to the consent. However, you are witnessing the physical signature, not the information provided. You should never sign as a witness if the client has not signed the consent form in your presence. As part of preoperative procedures, the nurse is also responsible for documenting that a signed consent has been placed in the client's chart

The client's arterial blood gases are pH 7.36; PCO2 37; HCO3- 24. How would the nurse describe these gases?1. Respiratory acidosis2. Metabolic alkalosis3. Respiratory alkalosis4. Normal

normal

The nurse is caring for a client receiving an antibiotic via a peripherally inserted central catheter (PICC). What two solutions should the nurse use to flush the line and keep it patent?

normal saline and heparin Rationale: When a PICC is being used intermittently, the nurse should flush the PICC after each use with normal saline and heparin to maintain patency. Sterile water is not used for flushing a PICC line. Heparin maintains patency.

Nurse Practitioner

performs health assessments, orders and interprets some lab and diagnostic tests, prescribe medications, health teaching and counseling

Julie is admitted to a surgical clinic in preparation for breast reduction surgery. During the initial assessment, she informs the nurse of her allergy to penicillin and notes that she smokes 10 cigarettes each day. Her vital signs are obtained. Drag and drop the action that the nurse should take next.

preoperative checklistThe nurse's priority activity is to initiate the preoperative checklist. Each facility's unique checklist will ensure that necessary documentation, admission assessment, physical preparation, and client education have been completed before the client enters the surgical suite.

Phamacist

prepares and dispenses pharmaceuticals, may monitor or evaluate actions and effects of medications information resource for patient and health care team

Chaplain (spiritual support personnel)

provide visits and ministry to patients and families

Nurse (LPN)

provides direct care under the direction of a RN or licensed practitioner

Which of the following vaccines would be important for an older client? Select all that apply. Tetanus Herpes zoster MMR Influenza Pneumococcal

tetanus herpes zoster influenza pneumococcal

purulent drainage

thick green, yellow, or brown drainage

The nurse obtains the wristband and allergy band for a preoperative client, Samuel. He confirms that this information on the bands is correct. The nurse reviews the information on the wristband with the client and asks him to name the procedure and surgical site. Drag and drop the action the nurse completed.

time-outA time-out, or "pause for cause," starts when the client enters the surgical facility. On admission, he or she receives a wristband printed with identifying information. After reviewing the wristband, the client confirms all information is correct. The nurse then has the client name the procedure and surgical site. This process is the first time-out before the client enters the surgical suite.

PT

treats movement dysfunctions by means of heat, water, exercise, massage, ultrasound, electric current

crushing injury

wound caused by force with a minimal break in the skin