HESI Fundamentals

celsius

temperature scale which water boils @ 100 degrees and freezes @ zero degrees.

TPR

temperature, pulse, respiration

Acute sinusitis symptoms would be

tender areas on the face with purulent nasal discharge

difficulty with extending the 4th and 5th finger of the left hand what should you do to obtain more information

this patient has dupytren and you should palpate the palm and assess for nodules and thickening

Release restraints at least every ____ hours.

2

Clubbing

convex nails

calcium blocker

-amil

RACE

-Rescue Patients -Alarm -Confine -Extinguish

Normal Phosphorus Level

2.7-4.5 mg/dL

Diarrhea nursing diagnosis

Diarrhea related to...

What supplements do pregnant women need to take?

Folic acid, iron, calcium (vitamin D)

euphea

normal breathing

R

rectal

AP

apical pulse

thickened liquids

risk for aspiration

Ax

under the arm ; axillary

Droplet precautions

-Wear gown, mask, gloves -Remove gloves first, then gown and mask

rhinosinusitis

cough and clear nasal dischargeky

strabimus

crossed eyes, should perform cover/uncover eye test

When administering oral meds through a gastrostomy tube

crush meds, dilute in water, let meds flow by gravity, and flush with 30 ml of water

Fine tremor of hands when holding the arms outstretched

postural tremor

common changes seen with aging

reduced upward gaze, sluggish pupil reflex, high frequency hearing loss, absent ankle reflex

subjective findings

S of SOAP ?? ??

After inserting an indwelling catheter into a male client and the flow of urine has started and you have inserted the length of tubing through client's meatus what should you do ?

Inflate the balloon with 10 ml of sterile water; after this step you can tap the catheter to client's leg

Why is a client with liver disease at increased risk of operative complications?

a. Impairs ability to detoxify medications used during surgery b. Impairs ability to produce prothrombin to reduce hemorrhage

Syringe sizes used for IM and subQ injections

1-3ml

The practical nurse (PN) is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site?

1-inch.

hemoglobin in females

12-15

Normal respirations for adults

12-20

hemoglobin in males

14-16

1 tablespoon is how many ml

15 ml

Normal respirations for adolescents

16-20

Normal specific gravity range

1.002 to 1.028

A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL

1.5

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.

2 Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

SBAR

Situation, background, assessment, recommendation

Normal respirations for children

20-30

The residual of stomach content should never exceed what

200 ml

BUN to creatine ratio

20:1

hco3

22-26

After 8 hours a patient should have how many ml of urine

240 ml

PT is 25 seconds whats that mean

25 seconds is above normal limits and indicates patient is at a high risk for bleeding (we prescribe vitamin K to reverse bleeding risk

Normal respirations for toddlers

25-32

You are planning a heparin injection for an obese patient. What technique will you use?

25G 1/2" needle, does not aspirate, injects at 90 degree angle, does not massage injection site (pay attention to key word: OBESE, so you know the needle length needs to be 1/2" rather than 5/8" and it must a be a 90 degree angle rather than 45)

Average rectal temp

37.5 (99.5)

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias

3,4,5 Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.

albumin

3.5-5.0

hematocrit to hemoglobin ratio of

3:1

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force

4

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 1 4 to 8 hours 2 12 to 24 hours 3 24 to 48 hours 4 72 to 96 hours

4 Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression 4 Acceptance

4 In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall

4 Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention

How long can a restraint order be good for?

4 hours for adults, 2 hours for children (9-17) and 1 hour for under 9

Normal WBC

4,500 to 11,000

Normal urine output

50-60 mL/hr or 1500 mL/day

A client's indwelling urinary catheter is removed at 9:30 AM. The practical nurse (PN) assesses the client every two hours for the desire to void. Which documented assessment requires further intervention by the PN?

5:30 pm: unable to void.

oxygen mask flow rates

6-15 L/min

Pulse range

60-100 bpm

nasal cannula cannot exceed

6L/ min

advocacy

acting on behalf of the client and protecting the client's right to make his or her own decisions

D Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.

87.An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. Correct Answer: D

Ethnicity

An individual's identification of self as a part of an ethnic group

What are the steps of the nursing process?

ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE -DOCUMENT-

For men, if the catheter will remain in place long-term, secure tubing to the ______ to prevent damage to penile-scrotal juncture.

Abdomen

An older client is receiving nasogastric tube (NGT) feedings for several days

Abdominal distention and nausea.

Asepsis

Absence of contamination (clean)

On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client?

Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.

Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings. Correct Answer: C

Utilitarianism

Act must result in the greatest good for the greatest number of people

A nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty?

Advocacy The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client's needs are met and by protecting the client's rights. Caring is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy. Confidentiality is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure.

What should you do with a PEG tube

After measuring the residual content the aspirate should be returned to the stomach

D Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Bleuler's 4 A's for schizophrenia

autism (preoccupied with self) affect (flat) associations (loose) ambivalence (difficulty making decisions)

mormon

avoid alcohol tobacco caffeine

During a counseling session a female and a male client begin arguing about what the male client just said what should you do?

Ask the female client to allow the male to continue talking without interruption

A client has brought in their own radio to a hospital room what do you do

Ask them not to use it until it can be checked by environmental services

Which action should the practical nurse (PN) take when drawing medication from an ampule?

Aspirate with a filter needle and syringe.

Which physical assessment technique involves listening to the sounds of the body?

Auscultation Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs

Direct contact transmission

Applied to care and handling of contaminated body fluids

A client who has a pressure-relieving mattress overlay is mobilized to a chair and imprints of the clients buttocks, heels, and scapula are evident on the mattress overlay. What action should the practical nurse implement?

Apply a different pressure relieving device and assess its effectiveness for this client.

Describe nursing care for a restrained client.

Apply restraints properly; check restraints frequently to see that they are not causing injury and record such monitoring; remove restraints as soon as possible; use restraints only as a last resort.

A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply.

Assault, Battery, False imprisonment Intentional torts include battery, assault, and false imprisonment. Unintentional torts include negligence and malpractice.

Which integumentary finding is related to skin texture?

Assessing for texture refers to the character of the surface of the skin. Assessing for elasticity determines the turgor of the skin. Assessing for vascularity determines skin circulation. Fluid buildup in the tissues indicates edema.

What should a patient do before having their blood pressure taken?

Avoid caffeine/smoking, rest 5 minutes before taking BP

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.

B) 1.5 ml

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.

B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request

minority group

ethnic, cultural, racial, or religious group that constitutes less than a numerical majority of the population

A Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

Paresthesia

refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body seen with carpal tunnel

Other Foods High in Sodium

Bacon Cheeses Ready-to-eat breakfast cereals Peanut butter Soups, commercially prepared, canned Corned beef

Which food should the practical nurse (PN) recommend for a client to increase the dietary intake of potassium.

Baked potato.

BPM

Beats per minute

Why should you think carefully before giving an antipyretic?

Because fever up to a certain point is beneficial

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.

C) Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. (A,B, and D)

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider.

C) Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation

Which action by the practical nurse (PN) demonstrates the value of dignity in client care?

Closes the door and covers the client during a bath.

eye movements

CN 3, 4, 5

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first. Correct Answer: B

Elimination in bedside chair

Can be delegated; remind assistant to report any abnormal findings

prone position

Can be used to palpate popliteal arteries

medications prescribed during post must be

renewed post op

The practical nurse (PN) hears breath sounds that are short, popping, and discontinuous on inspiration when auscultating a client's lungs. Which description should the PN document in the client's record?

Crackles auscultated.

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.

D) Ensure the accuracy of the blood type match All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed

D) Immediately after the assessments are completed Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.

D) Notify the healthcare provider of the family's request The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented

external disasters

events that occur outside the health care agency

Continuous tube feeding

Done continuously

Intermittent tube feedings

Done periodically

Lithotomy position

Dorsal recumbent position with feet in stirrups

Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status?

Daily body weight.

D Rationale: School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment

Stereotyping

Expectation that all people within the same racial, ethnic, or cultural group act alike and share the same beliefs and attitudes

Beneficence

Duty to do or promote good; taking positive actions to help others

Verocity

Duty to tell the truth

evaluations

E of SOAPIE

establish and maintain intermittent eye contact

E of SOLER (listening skills) ?? ?? ?? ?? ?? ??

Which food should the practical nurse (PN) recommend to a client as a source of complete protein?

Eggs.

In planning care for an older client on bed rest, which intervention should the practical nurse include in the prevention of pressure ulcers?

Elevate the head of the bed less that 30 degrees.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal disease One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy for the practical nurse (PN) to implement for the client's incontinence?

Establish a 2-hour voiding schedule.

The practical nurse (PN) is obtaining information for a male client's psychosocial assessment. Which action should the PN implement first?

Establish a therapeutic relationship.

The critical care pathway states that a patient recovering from shoulder surgery should be able to life arm to 45 degrees on the second day after surgery without assistance. The patient is unable to do so and you must change your care plan. Which step of the nursing process is the nurse completing this revision?

Evaluation

Which time frame should the practical nurse (PN) reposition a client?

Every 2 hours.

Pulse Ox site

Finger (remove nailpolish) or earlobe

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply.

Fingers and Earlobes Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Correct Answer: B

What do you perceive pain?

Frontal cortex

Basic contact precautions for protective environments

Hand hygiene before and after entering room; dispose of contaminated supplies in a way that prevents the spread of germs; use protective barriers; protect all persons who might be exposed during transport

malice

Hurting someone on purpose, or with reckless disregard for the truth

The practical nurse (PN) is caring for a client who is admitted with influenza and vomiting for 3 days. The client's skin turgor is poor and oral mucous membranes are dry. Which finding is most important for the practical nurse (PN) to report to the charge nurse?

Hypotension and tachycardia

A UAP may perform care that falls within which component of the nursing process?

Implementation

do not

Incident reports do/do not belong in patient's chart

facility

Incident reports help identify ?? issues needing attention/correction

Which technique should the practical nurse use to give a Z-tract intramuscular (IM) injection?

Inject the medication into the dorsal gluteal site.

When irrigating the external ear canals of an older adult client, which action should the practical nurse (PN) use to soften dry cerumen for removal?

Instill mineral oil in the external auditory canal overnight before irrigation.

I & O

Intake and output

Which statement defines "information" gathered by the nurse?

It is the organization and interpretation of data Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge

Thin, depressed, and concave nails implies

Koilonychia (often see in iron deficiency anemia)

Iodine

Marine fish, shellfish, dairy products, iodized salt, and some breads

Iron

Meats, eggs, legumes, whole grains, green leafy vegetables , and dried fruits

Heat application guidelines

Must have health care provider's orders

Nurse practice act

Nurses are required to be familiar with the laws that regulate their practice; used to measure appropriateness of nurses actions and behavior

NANDA

Nursing diagnoses must come from the ?? approved list

90.The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel.

Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. Correct Answer: D

Autonomy

Persons right to choose and the ability to act on that choice

84.Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. Correct Answer: D

While taking an adult's vital signs, the practical nurse (PN) notes an irregular radial pulse, What action should the PN implement to obtain the most accurate assessment?

Preform an apical-radial pulse assessment with another nurse.

NSAIDS decrease _______ response.

Prostaglandin (activate nociceptors so trigger pain)

Patient advocate

Protect patients human and legal rights and provide assistance in asserting these rights if the need arises

Wound dressings

Protect, aid in homeostasis, promotes healing, supports, promotes thermal insulation, protects client from seeing it; provides moist environment

Maslow's- Safety & Security

Protection from injury, promote feeling of security, trust in nurse-client relationship

The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing?

Remove all four sides by moving to the center of the incision.

Which site is best used to inspect a client who is suspected to have jaundice?

Sclera The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

deficit

Sensory ?? is reduced perception of sensory reception and perception

Croup

is most often caused by the HPIV and there is no vaccine available at this time

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium. Correct Answer: C

Intervention for insomnia

Sleep and exercise; encourage client to begin walking routinely during the day, but not 2-3 hours before bedtime

Dorsal recumbent position

Supine with knees flexed; used to promote relaxation of abdominal muscles

Accountability

Taking responsibility for ones actions

assessment diagnose plan implement evaluate

The 5 phases of the nursing process - ??, ??, ??, ??, and ??

split S2

is normal during inspiration

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.

The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.

The client should be positioned in a semi-sitting or Fowler's (B) position during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often referred to as a PEG tube, is inserted directly into the stomach through an incision in the abdomen and is used when long-term tube feedings are needed. In (A and/or C) positions, the client would be lying on his abdomen and on the tubing. In (D), the client would be lying flat on his back which would increase the chance of aspiration. Correct Answer: B

food water shelter clothing

The lowest level of the Maslow's pyramid is ??, ??, ??, and ??

B Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented. Correct Answer: D

68.Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record.

The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Correct Answer: C

storage refrigeration preparation

The proper ??, ??, and ?? of food is essential to be of value to the human body

The practical nurse (PN) is adding tap water to several medications for administration via feeding tube. Which preparation should the PN administer without delay?

Timed release capsule.

tachypnea

abnormally fast breathing

fever

abnormally high body temperature

The practical nurse (PN) contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints?

To ensure the client's safety when the benefits outweigh the risk.

A young woman, who is the primary caregiver for her mother who has Alzheimer's disease, tells the practical nurse (PN), "Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." What response should the PN offer?

What you do to cope with these feelings?

informed consent

To put a restraint on a patient, you have their ?? ??

Trousseau Sign

Trousseau sign of latent tetany is a medical sign observed in patients with low calcium. To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm.

Malpractice

Type of negligence; failure to meet the standards of acceptable care, which results in harm to another person

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

Use a pain scale to describe the intensity.

82.While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic.

When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated. Correct Answer: A

A Rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.

A Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

Magnesium

Whole grains, green leafy vegetables, tea, nuts, and fruit

Responsibility

Willingness to respect obligations; foloow through on promises

During insertion of a nasogastric tube (NGT) into the right nares, the client starts to cough. Which action should the practical nurse (PN) implement?

Withdraw the NGT to the oral pharynx, repostion client's head and reinsert.

15 minutes

You must check patient in a restraint every ?? ??

physicians written order

You must have a ?? ?? ?? to use a restraint

Cultural/spiritual nursing process

You must know yourself/your values before you can help the patient. Always.

2 hours

You must remove restraints every ?? ??

least restrictive

You must use the ?? ?? method for a restraint

To assess for residual urine the technique used it

a bladder scan

informed consent

a client's understanding of the reason for the proposed intervention, with its benefits and risks, and agreement with the treatment by signing a consent form

race

a grouping of people based on biological similarities; members of a racial group may have similar physical characteristics, such as blood group; facial features, and color of skin, hair and eyes

emergency response plan

a health care agency's preparedness and response plan in the event of a disaster

patient with ventricular septal defect you would hear

a murmur between S 1 and S2

A nurse cannot irrigate a wound without

a prescribed order

most common type of sleep apnea is caused by

airway collapse

Prothrombin time greater than 30 seconds places the client at risk for what?

bleeding

KCL 40 mEq IV now is your order what do you do

call doc to specify order because infusion rate and dilution are missing

Advanced roles of the RN

caregiver, communicator, teacher, client advocate, counselor, change agent, leader, manager and case manager

Patient with COPD has barrel chest this is consistent with

chronic hyperinflation

triage

classifying procedure that ranks clients according to need for medical care

Patient with irregular menstrual periods, weight gain, and hirsutism (excessive hair growth) would be experiencing a disorder of which body sysem

endocrine (not reproductive because weight gain and hair growth are not reproductive)

prioritizing

deciding which needs or problems require immediate action and which ones could tolerate a delay in action until a later time because they are not urgent

PICC line is changed how often

every 24 hours

F

farenheit

dullness

heard when percussing a solid organ (like liver, spleen, heart)

HR

heart rate

tympanic sounds

heart throughout abdomen

Systolic blood pressure readings obtained on the legs are usually

higher than those obtained in the arms so a bp of 160/80 from the leg is within normal limits

Patient with limited abduction and internal hip rotation, they have

hip disease

confusion in the elderly is often accepted as being part of growing old.

however, the confusion may be caused from dehydration and is usually due to a specific stressor

desensitization

is the nursing intervention for phobia disorders. --assess client to recognize the factors associated with feared stimuli. -teach and practice with client alternative coping strategies -expose client to feared stimuli -provide positive reinforcement

confabulation is not lying

it is used by the client to decrease anxiety and protect the ego

The key for restraints should

not leave the patient's room in case the need to be immediately removed

a transverse (horizontal) line across nail grooves (Beau's line)

occur in several illness

cultural assimilation

process in which individuals from a minority group are absorbed by the dominant culture and take on the characteristics of the dominant culture

malpractice

type of negligence; failure to meet the standards of acceptable care, which results in harm to another person

axillary

under the armpit

personality disorders are long standing behavioral traits that are maladaptive responses to anxiety and that cause difficulty in relating to and working with other individuals

persons with personality disorders are usually comfortable with their disorders and believe that they are right and the world is wrong and have little motivation

temporal

pertaining to the temple

A fully immunized child is experiencing coughing attacks, the nurse knows the coughing is most likely not caused by

pertussis, if child is fully immunized they have received the DPT vaccine which covers diphtheria, pertussis, and tetanus

lithium requires renal function assessment and monitoring

phenothiazines cause EPS (tardic dyskinesia can be permanent)

PMI

point of maximal impulse

acculturation

process of learning norms, beliefs, and behavioral expectations of a group other than one's own group

delegation

process of transferring a selected nursing task in a situation to an individual who is competent to perform that specific task

Patient is scheduled to have sutures removed but is not due for another dose of pain meds for hours what pain control method can you use to help the patient

progressive relaxation or guided imagery

An increased prothrombin time indicates

prolonged bleeding times

interprofessional collaboration

promotes sharing of expertise from health care professionals to create a plan of care that will restore and maintain a client's health

women who is breastfeeding need more

protein

femoral pulse

pulse felt in the groin over the femoral artery

carotid pulse

pulse felt on either side of the neck over the carotid artery

pedal pulse

pulse in the foot.

popliteal pulse

pulse located in the posterior of the knee

apical pulse

pulse normally heard at the heart's apex, usuallly gives the most accurate assessment of pulse rate

radial pulse

pulsed measured on the wrist over the radial artery

During suctioning repositioning a patient would

put them at risk for aspiration

the nurse should place an anxious client where there are reduced environmental stimuli

quiet area of the unit away from the nurse's station

what should you do to assess jugular venous distention in a client with heart failure

raise head of bed from 0 to 45 and measure from the highest point of visible distention to the sternal angle

If you hear expiratory wheezes over a patient's lower lobes what should you do

raise head of bed to a 60 degree angle to improve ventilation

dehydration in a newborn; you would also see

rapid pulse and sunken forehead

mucus membranes on your client are pale and the extremities are cool and white what else can you expect to see

rapid pulse because these are all signs of anemia

apical-radial pulse

reading done by measuring both the apical and radial pulse simultaneously, used when it is suspected that the heart is not effectively pumping blood.

right ventricle

receives more blood than left

2 year old aspirated a penny where do you think it will be lodged

right main bronchus, aspirated items are most likely to enter the right main bronchus and/or right lower lobe because the left main bronchus is smaller in diameter

when taking lie-sit-stand blood pressure you should use the same/different arms

same

side effects of antianxiety drugs

sedation, drowsiness

Which action should the practical nurse (PN) implement when administering a subcutaneous injection to a client who weighs 325 pounds?

select a needle with a longer shaft.

Symptoms of acute pancreatitis

severe gnawing epigastric pain that radiates to the back, and patient will assume the fetal postition

kussmaul's respirations

severe paroxysmal dyspnea as in diabetic acidosis and coma

Simple oxygen face-mask is suitable for

short-term oxygen therapy with lower oxygen concentrations

cirrhotic liver appears

shrunken

A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes?

"A nurse should provide a personal point of view." During the process of negotiating outcomes, the nurse is required to provide a personal point of view. Negotiations may take place informally at the client's bedside or in a formal setting. After gathering relevant information regarding an ethical dilemma, the nurse is required to examine his or her own values and formulate an opinion regarding the matter. When verbalizing the problem, the group agrees to a statement of the problem to begin discussions. This step is performed before negotiating outcomes. Negotiations take place after determining all possible courses of action.

A nursing student is listing the points that need to be remembered about the loss of a client's medical records. Which point listed by the nursing student is accurate?

"There is an assumption that the care provided to the client was negligent." In case a client's medical record is lost, there is an assumption that the care provided to the client was negligent. Loss of medical records may lead to a malpractice claim. The entire institution is responsible for maintaining medical records. Primary healthcare providers need to demonstrate why the medical records were lost. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement.

local anesthetic

-caine

dealing with delayed grief

-unresolved grief (determine level of dysfunction) -physical symptoms similar to those of the deceased -clinical depression -social isolation -failure to acknowledge loss

anti-viral

-vir

diuretic

-zide

Insulin syringes

.3-1 mL (calibrated in units). Most are 100 U

Hypotonic IV Solutions

0.45% Saline 0.22% Saline 0.33% Saline -Cause cell lyses -Deplete circulatory systems fluids -These solutions hydrate the cell -Don't use in patients with an increase in intracranial pressure, burns, trauma its w/ hypovolemia

Normal creatinine levels

0.5-1.2 mg/dL

creatine in women

0.6-1.2

protein

0.8 g/kg of body weight

creatine in men

0.8-1.4

Isotonic IV Solutions

0.9% Normal Saline 5% dextrose in water (D5W) 5% Dextrose in 0.225% Saline Lactated Ringers -Causes an increase in Extracellular fluid volume -Dehyrdration

Chain of infection (6 links)

1) Infectious agent 2) Reservoir 3) Portal of exit 4) Mode of transmission 5) Portal of entry 6) Susceptible host

Rights of medication

1) Right drug 2) Right patient 3) Right dose 4) Right route 5) Right time 6) Right documentation Others: 7) Right reason 8) Right to know 9) Right to refuse

What happens when someone has pain?

1) Transduction 2) Transmission 3) Perception 4) Modulation

A nursing student notes the characteristics of middle-range theories. Which points noted by the nursing student are accurate? Select all that apply.

1.Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response 2.Middle-range theories include Mishel's theory of uncertainty in illness, which focuses on a client's experiences with cancer while living with continual uncertainty. 3.Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories provide a basis to help nurses understand how clients cope with uncertainty and the illness response. Mishel's theory of uncertainty in illness is an example of a middle-range theory; it focuses on a client's experiences with cancer while living with continual uncertainty. Middle-range theories tend to focus on a specific field of nursing (such as uncertainty, incontinence, social support, quality of life, and caring) rather than reflect on a wide variety of nursing care situations. Middle-range theories are more limited in scope and less abstract than grand theories. Middle-range theories address a specific phenomenon and reflect practices such as administration, clinical, or teaching.

sodium

135-145; breads, cereal, canned foods

In emergencies, turn oxygen all the way up to ______ liters.

15

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. 1 Orientation 2 Capillary refill 3 Pupillary response 4 Respiratory rate 5 Pulse and skin temperature 6 Movement and sensation

2,5,6, A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

How far should a catheter be inserted?

2-3 inches for female; 7-9 inches for male

Fiber

20-35

Which age is considered the phallic stage according to Sigmund Freud's developmental theory?

3-6 years old According to Sigmund Freud's developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage a. Six to 12 years of age is the latent stage. Eighteen months to 3 years of age is the anal stage.

Potassium

3.5-5, bananas, fish (but not shellfish) whole grains, nuts, broccoli and cabbage, carrots, celery cucumbers potato skins, spinach, tomatoes appricots cantalope nectarine orange and tangerines

Normal CBC in women

3.90-5.03 million cells

1 oz is how many mL

30 ml

Normal respirations for infants

30-50

Normal respirations in newborns

35-40

Normal CBC in men

4.32-5.72 million cells

Hematocrit in male

42-52%

BUN

7-20

pH

7.35-7.45

calcium

8.5-10.5 dairy, rhubarb, spinach, tofu

Po2

80-100

PT Female

9.5-11.3 seconds

PT Male

9.6-11.8 seconds

What level should O2 stats remain above?

90%

borborygmi

A long continuous gurgling present in all four abdominal quadrants

B Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.

What is a stressor?

A stressor is any stimuli that can produce tension and cause instability within the system A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

What are the five rights of delegation?

A. Right task B. Right circumstance C. Right person D. Right direction or communication E. Right supervision

as evidenced by

AEB means

as manifested by

AMB means

67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience.

According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). Correct Answer: D

Cultural Competence

Acquisition of knowledge, understanding, and appreciation of a culture that facilitates provision of culturally appropriate health care

Advocacy

Acting on behalf of the client and protecting the client's rights to make his or her own decisions

91.The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond.

Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures. Correct Answer: B

When are syringes larger than 5 mL used?

Administer IV meds, add meds to IV solutions, irrigate wounds

For a patient with overactive bladder, you should tell them to

After urinating, wait a few minutes then try again, schedule a toilet break every 90 mins, don't run to the bathroom when you have the strong urge to go (double voiding technique releases residual urine and don't run with the urge you should try really hard to stay on the 90 minute schedule and regain control of your bladder.

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Correct Answer: D

used to treat ventricular fibrillation and unstable ventricular tachycardia

Amiodarone

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D). Correct Answer: A

A male client is upset with the healthcare provider's recommendation that he should consent to an above-knee amputation. He tells the practical nurse (PN), if they want to cut off my leg, they should just shoot me instead. How should the PN respond?

Ask the client how the surgery might effect his lifestyle.

The male client who is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." which action should the PN implement first?

Assist the client to a supine position.

Certification

Beyond NCLEX-RN; exam in nursing specialty; minimum practice requirements are set depending in the certification; include years required working in specialty area

Ethic of care

Caring, promoting dignity

Paralytic ileus

Cessation of bowel peristalsis

What do you do first if you commit a medication error?

Check the patient (take VS)

Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems?

Counselor As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. A nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care.

Which finding indicates to the practical nurse (PN) that an older client who is receiving intravenous therapy is experiencing fluid overload?

Crackles in the lung fields.

to expel residual from the bladder what technique is used

Crede method (it will not provide accurate assessment of amount of urinary retention)

Which intrinsic factor is associated with the fall of an older adult?

Deconditioning Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area.

Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D). Correct Answer: B

IM site/ ventrogluteal

Deep site situated away from major nerves and blood vessels; less chance of contamination; easily ID by bony landmarks; total IM volume is 3mL

Deontology

Defines actions as right or wrong; looks to the presence of principle regardless of outcome

A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction?

Descriptive theories help direct specific nursing activities. Descriptive theories do not direct specific nursing activities. Instead, they help to explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.

The practical nurse (PN) identifies a client's need for spiritual support. What is the first action the PN should take?

Determine the client's perceptions and belief system.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Correct Answer: B

Orthopneic position

For shortness of breath; leaning forward over a table with a pillow

1 3

High O2 can cause death within ? to ? minutes

clinical manifestation that occurs with hemorrhage

Increased heart rate

5 stages of infection

Incubation, prodromal, illness, decline, convalescence

The practical nurse (PN) is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, and increase in granulation tissue development within two weeks, which intervention should the PN implement?

Irrigate wound with sterile normal saline.

Which theorist suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptations to their environments?

King According to King's theory, the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. According to Peplau's theory, the goal of nursing is to develop an interaction between nurse and client. According to Nightingale's theory, the goal of nursing is to facilitate the reparative processes of the body by manipulating a client's environment. According to Benner and Wrubel, the goal of nursing is to focus on a client's need for caring as a means of coping with stressors of illness.

Bolus tube feeding

Large feeding done over 20-30 minutes

Fowler's and semi-Fowler's position

Laying on back with head of bed elevated 60 degrees for Fowler's and 30-45 degrees for semi-Fowler's

Maslow's- Self-Actualization

Least priority- Hope, Spiritual well-being, enhanced growth

Which position is best for the practical nurse to place the client during administration of a rectal suppository for constipation?

Left Sim's position with upper leg flexed.

The practical nurse (PN) observes a client who begins to choke during a meal. determining that the client cannot speak, what action should the PN implement?

Place a fist halfway between the xiphoid process and umbilicus.

sit facing the client

S of SOLER (listening skills) ?? ?? ?? ??

Which definition is involved in the caring process called knowing according to Swanson's theory of caring?

Striving to understand an event as it has meaning in the life of the other In Swanson's theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

Values

Strongly held personal beliefs about the worth and importance of an idea, attitude, custom or object that sets standards that influence behavior

What position should the practical nurse (PN) place a client in who is receiving an enteral tube feeding?

Supine with the head of the bed elevated 30 to 45 degrees.

related factor

The condition identified in the client's assessment data is called the ?? ?? (R/T)

When initiating oxygen through a non-rebreathing mask the nurse should

The reservoir bag should be filled with oxygen before the mask is placed on the face

Utilitarian =

The rightness or wrongness of an action depends on the consequences of the action.

heart disease cancer cerebrovascular disease

The top three causes of death are ?? ??, ??, and ?? ??

The practical nurse (PN) is irrigation a client's indwelling urinary catheter, After injection normal saline as prescribed, what action should the PN implement?

Unclamp the tubing and lower the collection bag.

Droplet precautions

Used for diseases that are transmitted by large droplets that are expelled into the air 3-6 feet. Mask, hand hygiene, dedicated care equipment. Ex. influenza

Airborne precautions

Used for diseases that are transmitted by smaller droplets that remain in the hair for long periods of time. Requires negative air flow; air filtered through HEPA filter

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply.

Using Pincer Grasp well Picking up small objects Showing hand preference The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.

Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A

JP drain

Usually is inserted in surgery and Allows for accurate measurement of wound drainage

Digital removal can stimulate the _____ nerve, so stop the procedure if the patient accumulates bradycardia.

Vagus

What is the preferred IM site for infants?

Vastus lateralis muscle

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?

Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference. Correct Answer: B

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply.

Worth and Achievement Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

An older male client who is incontinent receives a prescription for a condom catheter. Which step(s) should the practical nurse implement when applying the external catheter? (select all that apply)

Wrap the adhesive strip in a spiral around the penis. Apply skin prep to the penile shaft and allow to dry. Leave 1 to 2 inches between the tip of the penis and condom catheter.

Advance directive

Written document recognized by state law that provides directions concerning the provision of care when a client is unable to make his or her own treatment choices; living will and durable power of attorney

libel

Written slander

During palpation of the thorax you feel a quarter sized area of pulsation in the 6th intercostal space along the lateral axillary line what else is a likely finding

a low frequency gallop heard just before S1

one eye being red or unilateral redness suggests

a toxic, chemical, or mechanical origin of conjunctivitis

Common causes of fluid volume overload:

a. Heart failure b. Renal failure c. Cirrhosis d. Excess ingestion of table salt e. Overhydration with sodium containing fluids

the nurse should suspect an imminent suicide attempt if a depressed client becomes "better"

be aware a happy affect may signify the the client feels relieved that a plan has been made and is prepared for the suicide attempt

the nurse knows depressed clients are improving when they

begin to take an interest in their appearance or begin to perform self-care activities

C

celsius

Client who takes prednisone for asthma reports difficulty sleeping what should the nurse do first

consult physician to change medication time to earlier in the day

If a patient who is terminally ill asks for no more treatment and says they want to go home to die you should

contact the physician about patient's decision

systole

contraction of the heartbeat systolic blood pressure; pressure of the blood against the walls of the artery

when a person is hemorrhaging the bp

decreases

the basic difference between delirium and dementia is ...

delirium is acute and reversible but dementia is gradual and permanent

Patient with obstructive sleep apnea (chronic) has low PaO2 and high PCO2 what intervention should you implement

demonstrate how to use a positive airway pressure to device in order to prevent the airways from collapsing during sleep and maintains airflow through the night

Which organs can be assessed through the left lumbar region of the abdomen

descending colon and lower half of left kidney

cultural diversity

differences among groups of people that result from ethnic, racial, and cultural variables

dyspnea

difficulty breathing

racism

discrimination directed toward individuals or groups who are perceived to be inferior

Once the nursing diagnoses have been prioritized the next step when planning the client's care would be to

discuss goals of care with the patient

rectal

distal portion of the large intestines between the sigmoid colon and the anal canal

TM

ear canal

tempanic

ear/eardrum

hypertension

elevated blood pressure

pretibial myxedma

erythema, thickening, and induration of the skin overlying the shins which is associated with graves disease

dominant culture

group whose values prevail within a society

classical triad of mononucleosis is

low-grade fever, cervical lympadenopathy and pharyngitis so you should also inspect the throat and oral cavity for tonsillar enlargement

flaky, crusty, erythematous skin around areolar can be

mammory pagent disease which is a sign of underlying breast cancer

SBP

systolic blood pressure

Fidelity

Faithfulness; obligation to keep promises

What is the most common incident reported in hospitals?

Falls

Identify two examples of isotonic IV fluids.

a. Ringers lactate b. Normal saline

stertorous breathing

breathing that occurs when air travels through secretions in the air passage; snoring

For an IV catheter where should you put it

cephalic vein; brachial is too high up

apnea

cessatation of breathing

provide a consistent caregiver is priority in planning nursing care for the confused older client

change increases anxiety and confusion

oral thrush is associated with

chronic use of inhalation of corticosteroids in clients with asthma

hand sanitization

cleansing the hands using a chemical agent or thorough hand washing.

pure liquid

clear liquid no pulp jello is okay

You never squirt an enema

the enema should never be administered with force, but rather allow gravity to regulate the flow

During the evaluation phase the nurse determines if

the established goals were met and if adjustments to the care plan are needed.

patient is bedfast with CHF and diabetes at risk for skin breakdown what should be addressed first

the fact that the client is in the fowler's position which puts them at severe risk of pressure ulcer development

When evaluating outcomes of care look at

the goals established in nursing diagnosis

pulse

the heartbeat as felt through the walls of the srteries and the skin or as heard at the apex of the heart with a stethoscope

the child/adolescent's lack of remorse about antisocial behavior represents a malfunction of the superego

the id functions on the basic instinct level and strives to meet immediate needs. the ego is in touch with external reality and is the part of personality that makes decisions

ethics

the ideals of right and wrong; guiding principles that individuals may use to make decisions

acupuncture

the insertion of needles at various points on the body to relieve pain -invasive -associated with the gate control theory -thought to increase the production of endogenous opiates

culture

the knowledge, beliefs, patterns of behavior, ideas, attitudes, values, and patterns of behavior on individuals from another culture

rape victims are at high risk for PTSD. immediate intervention to diminish distress is vital.

the nurse should also assess for and intervene for sequelae such as unwanted pregnancy, STD's, and HIV

be aware of your own feelings when dealing with this somatoform clients.

the pain is real to the person experiencing it

Client's Bill of Rights

the rights and responsibilities of clients receiving care

crisis

the turning point of a disease with intensification of symptoms

avoid giving clients with dissociative disorders too much information about past events at one time

the various types of amnestic that accompany dissociative disorders provide protection from pain and too much to soon can cause decompensation

women who are abused may rationalize the spouse's behavior and unnecessarily accept blame for his actions.

the woman may or may not choose to press charges. be sure to give her the number of a shelter or help line

observe for increased motor activity and erratic response to staff and other clients

client may experiencing an increase in command in hallucinations, when this occurs there is an increased potential for aggressive behavior

S2

closing of the aortic and pulmonic valves

S1

closing of the mitral and tricuspid valves sound

depressed clients have difficulty hearing and accepting compliments because of their lowered self-concept

comment on signs of improvement by noting behavior

people with anorexia gain pleasure from providing others with food and watching them eat

these behaviors reinforce their perception of self-control. don not allow these clients to plan or prepare food for unit-based activities

provide consistent interventions for children

this helps to prevent manipulation because inconsistency does not help the client develop self control

when dealing with a depressed client the nurse should assist with personal hygiene tasks and encourage the client to initiate grooming activities even when they dont feel like doing so

this helps to promote self-esteem and a sense of control

the purpose of therapeutic interaction

to allow the client to autonomy to make choices when appropriate. keep statements value-free, advice free, and reassurance-free

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education?

"I should monitor weight and food intake once in a month." The nurse should monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse should serve food that is easy to eat provide assistance with eating. The nurse should also offer food supplements that are tasty and easy to swallow.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

"It is performed routinely starting at your age as part of an assessment for colon cancer." The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

A registered nurse is explaining the term "just culture" to the student nurse. Which explanation provided by the registered nurse is accurate?

"It refers to promoting open discussion whenever error occurs without fear of recrimination." The term "just culture" refers to the promotion of open discussion whenever errors occur without fear of recrimination. Fidelity refers to the agreement to keep promises. Beneficence refers to taking positive actions to help others. Accountability refers to the ability to answer for one's actions.

Airborne precautions

-Includes TB, varicella (chickenpox), SARS (pneumonia), and rubeola (measles) -Wear gown, N-95 mask, gloves -Remove mask OUTSIDE the room after closing the door

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?

"Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response?

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

Contact precautions

-Most common form of transmission -Use gown and gloves -Remove PPE and wash hands BEFORE leaving room

The mother of an infant with cerebral palsy asks if her child is going to die, how do you respond?

"your child's condition is very serious and will likely cause him to pass away at a an early age" you need to be honest and answer her questions

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.

(B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct Answer: B

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

(C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem. Correct Answer: C

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.

(C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct Answer: C

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client. Correct Answer: D

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct Answer: D

Maslow's- Basic Physiological Needs

(Priority)- Airway, Respiratory effort, heart rate, rhythm and strength of contraction, nutrition, elimination

Hypertonic IV Solutions

-3% saline -5% Saline -10% Dextrose in Water -5% Dextrose in 0.9% Saline -5% Dextrose in 0.45% Saline -5% Dextrose in LR -Causes the cell to shrink, fluid overload w/pulmonary edema -Give to patients with cerebral edema (reduces pressure), hyponatremia (pulls sodium back into the intravascular system)

preparation for death

-Denial: coping style used to protect self/ego; non compliance, refusal to seek treatment, ignoring symptoms; changing the subject when speaking about illness; stating, "not me, it must be a mistake." -Anger: often directing it a t family or health care team members; stating, "why me? it's not fair." -Bargaining: making a deal with God to prolong life; usually not sharing this with anyone, keeping it a very private experience -Depression: results from the losses experienced because of health status & hospitalization; anticipating the loss of life -Acceptance: accepting the inevitable; beginning to separate emotionally

Hyponatremia Signs

-Hyperactive Bowels Sounds -Muscle Weakness -Increased Urine Output -Decreased specific gravity of urine would be noted

Protective, or reverse isolation

-Immunosuppressed patients (low WBC counts, chemotherapy, large open wounds) -Make sure equipment is disinfected BEFORE it is taken into the room

Activated Partial Thromboplastin

-The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. -The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. -This means that the client's value should not be less than 30 seconds or greater than 90 seconds.

What is the site of choice for IM injections?

-Ventrogluteal muscle -Landmarks are the greater trochanter, anterior superior iliac spine, and iliac crest

Troponin

-a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. -Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. - A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. -A normal troponin I level is lower than 0.6 ng/mL.

theses disorders cannot be explained medically, it results from internal conflict. the nurse should...

-acknowledge the symptom or complaint -reaffirm that diagnostic test results reveal no organic pathology -determine the secondary gains acquired by the client

ford clients with PTSD, the nurse should....

-actively listen to client's stories of experiences surrounding the traumatic event -assess suicide risk -assist client to develop objectivity about the event and problem solve regarding possible means of controlling anxiety related to the event -encourage group therapy with other clients who have experienced the same traumatic event

as long as the client's acts are free of violence: nurse should....

-actively listen to the clients obsessive themes -acknowledge the effects that ritualistic acts have on the client -demonstrate empathy -avoid being judgmental

Early Signs of Hypoxia

-anxiety, -restlessness -inability to concentrate -increases in heart rate -increased respiratory rate and blood pressure -cardiac dysrhythmias

anti-ulcer

-dine

opioid analgesic

-done

oral hypoglycemic

-ide

anxiety

-lam

nursing interventions for confused elderly

-maintain client's health and safety -encourage self care -reinforce reality orientation -provide safe, consistent environment

Ab

-micin

diuretic

-mide

Ab

-mycin

Chronic pain

-nonmalignant (low back pain, rheumatoid arthritis etc.) -intermittent (migraine headaches etc.) -malignant, associated w/ neoplastic diseases

neuromuscular blocker

-nuim

beta blocker

-olol

broad Ab

-oxacin

anxiety

-pam

Signs of Hypocalcemia

-paresthesias followed by numbness -hyperactive deep tendon reflexes -a positive Trousseau's or Chvostek's sign -neuromuscular excitability -muscle cramps -twitching -tetany -seizures, irritability, and anxiety -increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

Calcium blocker

-pine

ace inhibitor

-pril

what intervention should the nurse use if the client becomes abusive

-redirect negative behavior -suggest a walk -set limits on intrusive behavior -seclude or administer medication

s/s of depression

-significant change in appetite -insomnia -fatigue or lack of energy -feelings of hopelessness -loss of ability to concentrate -preoccupation with death or suicide

steroid

-sone

antihyperlipidemic

-statin

Acute pain

-temporary -occurs after an injury to the body -includes postoperative pain, labor pain, renal calculus pain

3 checks of safe medication administration

1) Before you pour, mix, or draw up a medication 2) After you prepare the medication 3) At the bedside

Which theory details nursing interventions for a specific phenomenon and the expected outcome of care?

Prescriptive Theories Prescriptive theories detail nursing interventions for a specific phenomenon and the expected outcome of the care. Grand theories provide the structural framework for broad, abstract ideas about nursing. Predictive theories identify conditions or factors that predict a phenomenon. Descriptive theories help to explain client assessments.

stage 1

Pressure ulcer showing intact skin with nonblanchable redness of a localized area

stage 2

Pressure ulcer showing partial-thickness skin loss involving epidermis, dermis, or both

stage 3

Pressure ulcer where full-thickness skin loss; subcutaneous fat may be visible, but bone, tendon, or muscles are not

A Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.

Don'ts for applying heat/cold therapy

Don't let client adjust temp; don't allow client to move application or place hands on wound; make sure client can move away from temp source; don't leave client who can't feel temp changes

A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1 White blood cell (WBC) count of 15,000 mm3 2 Negative protein in the urine 3 Blood urea nitrogen (BUN) of 20 mg/dL 4 Prothrombin of 12.0 seconds

1 White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply.

1 Interventions to restore tissue integrity 2 Interventions to optimize neurologic functions 3. Interventions to provide care before, during, and immediately after surgery Interventions such as restoring tissue integrity, optimizing neurologic functions, and providing care before, during, and immediately after surgery are classified under physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy [1] [2]. Interventions to manage restricted body movements are classified under the simple physiologic domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs

1,2,5 With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation

1,3 Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members.

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. 1 Ask the client what is the client's acceptable level of pain. 2 Eliminate all activities that precipitate the pain. 3 Administer the pain medications regularly around the clock. 4 Use a different pain scale each time to promote patient education. 5 Assess the client's pain every 15 minutes

1,3 The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals.

The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear

1,3,4 Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning of procedure. 4 Instill the solution directly onto cornea. 5 Press on the nasolacrimal duct after instilling the solution.

1,3,5 Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client's health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client's response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client's care. The nurse selects interventions (nursing and collaborative) individualized to each of the client's nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client's response and whether the interventions were effective. The nursing process is dynamic and continuous.

A registered nurse is teaching a nursing student about systems theories with a specific reference to Neuman's systems theory. Which statements made by the nursing student post teaching are accurate? Select all that apply.

1. Factors that change the environment also affect an open system. 2.The components are interrelated and share a common purpose to form a whole. 3.An open system interacts with the environment, with an exchange of information between the system and the environment. Factors that change the environment also affect an open system. The components are interrelated and share a common purpose to form a whole. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. A system is composed of separate components, and there are two types of system, open or closed. Neuman's systems theory defines a total-person model of holism and an open-systems approach

A nursing student is examining the health services pyramid. Keeping in mind that care services begin at the bottom of this pyramid, in which order should care services be arranged?

1. Population based services 2.Clinical preventative services 3.Primary health care 4.Secondary health care 5.Tertiary health care According to the health services pyramid, population-based health care services come first. Clinical preventive services form the next level of the pyramid. A nurse should then address the primary health care needs of clients; these needs include prenatal and baby care and nutrition counseling. The next level of health care is secondary health care services, which include emergency care and acute medical-surgical care. Tertiary health care forms the highest level of health care; these needs include intensive care and subacute care.

Warfarin Therapeutic PT

1.5 - 2 times higher than the normal level. Approx. 18-23 seconds

Magnesium

1.5-2.5, cashews halibut swiss chard leafy greens, tofu, dried fruit

phosphate

1.7-2.6 milk meat nuts legumes grains

What is the most BP can vary between arms and still be considered normal?

10

The accepted range of oxygen delivery with a non-rebreather mask is

10 to 15 L/min.

Respiration range

12-20 bpm

Prehypertension range

120-139/80-89

Stage 1 Hypertension

140-159/90-99

A client is receiving a Mantouz test for tuberculosis screening. Which angle should the practical nurse (PN) insert the needle for injection?

15 degrees.

Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.

15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B). Correct Answer: B

After administering intravenous medication, check the patient in

15 to 30 minutes for relief from pain

Non-rebreather masks require how many L/min to stat inflated

15L/minute

Tuberculin syringe

16ths of minim and 100ths of a mL. (capacity of 1mL). intradermal or subQ

Sedation rating scale

1=awake and alert 2=slightly drowsy, easily aroused 3=frequently drowsy, arousable by voice 4=arousable by shaking* 5=somnolent, not arousable* *Stimulate patient and notify physician

stage 4

Pressure ulcer where full-thickness tissue loss with exposed bone, tendon, or muscle

During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? 1 The nurse also should have instituted a plan to increase activity. 2 The nurse provided supportive nursing care for the well-being of the client. 3 Debridement of the pressure ulcer should have been done before the dressing was applied. 4 Treatment should not have been instituted until the health care provider's prescriptions were received.

2 According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions.

unstageable

Pressure ulcer where wound cannot be visualized; ulcer is full-thickness tissue loss in which base of the ulcer is covered by slough, typically has eschar

compulsive acts are used in response to anxiety, which may or may not be related to the obsession. its the nurse's responsibility help alleviate anxiety

its the nurse's responsibility help alleviate anxiety, interfering will increase the anxiety

secondary amenorrhea is

lack of menstruation for more than 6 months in a menopausal female

mitral valve stenosis enlarges which heart chamber

left atrium

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. 1 After reporting severe pain 2 On admission to the hospital 3 Upon entering the operating room 4 Before transfer to a rehabilitation facility 5 At time of scheduling for the surgical procedure

2, 4 Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause

3 Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue

3 A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Incorrect1 Occipital headache 2 Periorbital crepitus 3 Expectoration of blood 4 Changes in vocalization

3 After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer

3 Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.

to insert an NG tube to and UNCONSCIOUS patient, what position should they be in

left side-lying

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism

3 When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

phosphorus

3-4.5

When blood pressure is lower in the arms than legs what is suspected

peripheral vascular disease

Normal serum potassium levels are

3.5-5.0

pCo2

35-45

hematocrit in female

35-47%

Temperature range for adults

36-38 C (96.8-100.4 F)

Average axillary temp

36.5 (97.7)

Average oral temp

37 (98.6)

Nursing actions that prevent postoperative wound dehiscence and evisceration:

a. Teaching client to splint incision when coughing b. Encouraging coughing and deep breathing in early postoperative period when sutures are strong. c. Monitoring for signs of infection d. Malnutrition e. Dehydration f. Encouraging high-protein diet

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

4 A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

Evidence-based practice

Approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care

cultural imposition

tendency to impose one's own beliefs, values, and patterns of behavior on individuals from another culture

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)

4 Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance

4 Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? 1 Prolonged use can cause dark concentrated urine. 2 The medication is best absorbed when taken on an empty stomach. 3 Take the medication with aluminum hydroxide to minimize GI upset. 4 Drinking alcohol daily can cause drug-induced hepatitis

4 Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.

first sign of puberty in males

testicular enlargement

A valid outcome criteria to evaluate the risk of compartment syndrome in the lower extremities is

testing capillary refill (should be less than 3 seconds)

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site

4 This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.

chloride

95-105, seaweed, rye, tomatoes lettuce celery olives table salt

Max ml to administer IM medication in deltoid

< 1 ml

triglyceride levels in females

<135

Urine output indicating renal failure

<30 mL/hr

triglyceride levels in males

<60 mg/dL

first systolic bp should be

>10 if not auscultate the heart

LDL

>130

total cholesterol

>200

(HDL) cholesterol are_____ for males

>45 mg/dL

(HDL) cholesterol are_____ for females

>55 mg/dL

protective equipment

?? ?? alllogenic hymatopoietic stem cell transplants; private room

risk factors

?? ?? are cues or clues which indicate diagnosis is applicable to the clients condition

diagnostic label

?? ?? is another term for the nursing diagnosis (from NANDA)

false imprisonment

?? ?? is restraining a client without justification (w/o physicians written order)

definition

?? helps describe the characteristics of the condition

negligence

?? is conduct that falls below the standard of care

battery

?? is intentional touching without consent

malpractice

?? is professional negligence

etiology

?? is what which is within the nursing domain of practice

slander

?? is when one makes false VERBAL statements

hypothermia

?? is when the body's core temp is below 95F

hyperthermia

?? is when the body's core temp is too high

assault

?? may be actual or threatened, such as giving an injection or threatening to restrain a client who has refused a procedure

ALL

?? other appropriate methods must have been exhausted before using a restraint

contact

?? precaution is direct client or contact - MRDO such as VRE or MRSA, RSV, scabies

airborne

?? precautions are for droplet nuclei smaller than 5 mcg - measles, chickenpox

droplet

?? precautions are for droplets larger than 5 mcg being within 3 feet of client - pneumonias, plague, pertussis, mumps

support

?? the diagnostic statement with specific assessment data which has defining characteristics proving the accurate nursing diagnosis

CO2

??? is a colorless, ordorless gas that is emitted from improperly set furnaces, heaters, and stoves

List four interventions that prevent postoperative thrombophlebitis.

a. Teaching performance of in bed leg exercises b. Encouraging early ambulation c. Applying antiembolus stockings d. Teaching avoidance of positions and pressures that obstruct venous flow

normal ABGs

a. pH: 7.35-7.45 b. PaCO2: 35-45 c. HCO3: 22-26

B Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated. Correct Answer: B

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred. Correct Answer: D

D Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.

D Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.

A Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void.

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill.

C Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

tachycardia

abnormally high heart beat

hypotension

abnormally low blood pressure

bradycardia

abnormally slow breathing/respiration

palpatation

the act of feeling with the hand, placing two fingers on the body to determing the condition of the underlying part

D Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.

C Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990

C Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics.

A Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B

Standards of practice

A list of standards to assist the professional in making good decisions while conducting day to day responsibilities within his or her scope of practice.

A Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication.

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control.

Licensure

A mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors

Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy

A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?

A Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury

select only one nurse to care for an abused child

abused children have difficulty establishing trust, and the child will be less anxious with one consistent caregiver

C Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

assessment

A of SOAP

What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare?

A proxy is a legal document that designates a person or persons to make health care decisions on behalf of the client. Healthcare proxies enable another person or persons to make healthcare decisions on the client's behalf when the client is no longer able to make decisions on his or her own. The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs. This act is not related to healthcare proxies. The ethical doctrine of autonomy ensures the client's right to refuse medical treatment. A living will is a written document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.

A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care. Correct Answer: C

B Rationale: The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.

A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.

How does the World Health Organization (WHO) define "health"?

A state of complete physical, mental, and social well-being The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

89.What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed.

A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned. Correct Answer: A

Following a cholecystectomy, a client asks the practical nurse (PN) about dietary restrictions that may need to be followed. Which diet should the PN recommend?

A well-balanced diet with no other restrictions.

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.

A) Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement

management

accomplishment of tasks or goals by oneself or by directing others

cultural competence

acquisition of knowledge, understanding, and appreciation of a culture that facilitates provision of culturally appropriate health care

Showering with an IV

Adjust IV flow rate to KVO and remove IV tubing from pump. Reset after shower is over.

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan?

Administering general anesthetic to the client Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation?

Advocate The nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager uses appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services within a health care agency.

B Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.

C Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.

ABC's

Airway, breathing, circulation

Low levels of _____ are associated with malnutrition.

Albumin

Which statement regarding Roy's theory of nursing needs correction?

All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

ANA

American Nurses Association; concerned with legal aspects of nursing

Certified Nurse-Midwife (CNM)

An APRN who is also educated in midwifery and is certified by the American College of Nurse-Midwifes

Clinical Nurse Specialist (CNS)

An APRN who is an expert clinician in a specialized area of practice

Nurse Practitioner (NP)

An APRN who provides health care to a group of patients, usually in an outpatient, ambulatory care or community-based setting

Certified Registered Nurse Anesthetist (CRNA)

An APRN with advanced education in a nurse anesthetia accredited program

Deontologic =

An action is right or wrong independent of its consequences.

When ambulating down the hall your patient frequently stops to talk or adjusts clothing before walking again what is this a sign of

activity intolerance

C Rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

A Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D). Correct Answer: A

86.A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies.

Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members. Correct Answer: D

When evaluating if the plan of care has been followed look at

the actions implemented in care

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake?

Assessment The documentation of the client's information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the doctor understand the client's history a make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client's problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client's problems and then the plan is implemented. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

Which assessment is expected when a client is placed in the lithotomy position during physical examination?

Assessment of female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history?

Attention Span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation

B) During the inhalation The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C).

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.

B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). Correct Answer: A

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct Answer: B

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement. Correct Answer: C

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement. Correct Answer: C

Condiments High in Sodium:

Bouillon cubes Mustard Olives, pickled, canned or bottled Pickles, cucumber, dill Salad dressings, commercially prepared Soy Sauce

The practical nurse (PN) identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN?

Bowel movements decrease to one every third day.

What is prune juice used for?

Bowel stimulation

the radial artery is being considered for a client needing cardiac bypass surgery. What is most important for nurse to do

compress radial and ulnar artery; observe for flushing of the hand when pressure over the ulnar is released (allen test; used to assess the blood supply to the hand and the patency of the ulnar artery

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.

C) Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.

C) Examining a chest x-ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified

C) Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.

C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase

C. diff

Can't use hand sanitizer; must wash with soap and water

Vegetables High in Sodium:

Canned vegetables Carrots, particularly canned Tomatoes, particularly canned Tomato, catsup Tomato juice

NG tubes

Cannot be delegated; have patient sip water; can go into lungs; clients w; impaired LOC are at risk for aspiration

An older female states that the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse (PN) take?

Check the written prescription to verify the medication.

Potassium

Citrus fruits, and dried fruit , bananas, watermelon, potatoes, legumes, tea, and peanut butter

what should be collected using sterile technique and in sterile containers

Clean-catch urine, urine from a Foley catheter, wound drainage, and sputum

Which intervention should the practical nurse (PN) implement to reduce the incidence of urinary tract infections in a client with an indwelling catheter?

Cleanse perineum area with soap and water BID and PRN.

How can a nurse best evaluate the effectiveness of communication with a client?

Client Feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

Which client group is most likely to experience a therapeutic response from therapeutic touch?

Clients with headaches.

Career options for the RN

Clinical specialist, nurse practitioner, midwife, anesthetist, educator, entrepreneur, administrator

A client whose diet is low in fiber is at risk for which condition?

Colon cancer.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.

Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice. Correct Answer: D

Negligence

Conduct that falls below a standard of care; failure to meet a client's needs either willfully or by omission or failure to act

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect?

Contact Dermatitis A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

What items should the nurse assist the client in removing before surgery?

Contact lenses; Glasses; Dentures; Partial plates; Wigs; Jewelry; Prosthesis; Makeup; Nail polish.

Maslow's- Self-Esteem

Control, Competence, Positive regard, Acceptance/worthiness

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D). Correct Answer: C

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes. Correct Answer: C

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions

D) Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity

An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.

D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C).

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Correct Answer: D

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Correct Answer: D

70.The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance.

Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. Correct Answer: D

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). Correct Answer: A

An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the practical nurse (PN) that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first?

Digitally assess for impacted stool.

An older client who has been on bed rest in not eating well and is exhibiting abdominal distension, cramping, and is passing small amounts of liquid stool. Which prescribed action is most important for the practical nurse (PN) to implement?

Digitally remove a fecal impaction.

Two types of contact transmission

Direct and indirect

When irrigating the eyes of a client, which action should the practical nurse implement?

Direct the irrigation flow from the inner canthus to the outter canthus of the affected eye.

After giving the proper dosage of a narcotic to your patient you have some left over what do you do with it?

Dispose of vial immediately with a witness

When giving a bed bath, wash from _____ to _____.

Distal to proximal (upward motion to increase circulation)

A client is prescribed a medication that is labeled as a sustained released (SR). What action should the practical nurse (PN) implement when administering this drug form?

Do not crush or dissolve the tablet or capsule contents.

The practical nurse (PN) is obtaining the vital signs for a client who has a urinary tract infection with Methicillin-resistant Staphylococcus Aureus (MRSA). How should the PN proceed?

Don a gown and gloves before entering the room.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an n95 mask when entering room A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

D Rationale: Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having.

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns.

80.While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down.

During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). Correct Answer: D

B Rationale: During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply.

Emotional Status and Growth and Development Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring?

Enabling The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

An older female recently diagnosed with coronary artery disease (CAD) cooks at home using saturated fats, Which intervention should the practical nurse implement to help the client reduce modifiable risk factor(s)?

Encourage food preparation with various vegetable oils.

Which intervention should the practical nurse (PN) implement to help a client cope effectively with chronic pain?

Encourage using relaxation techniques.

The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated. Correct Answer: B

An African man presents to the emergency department to obtain pain medication. The nurse behaves judgmentally and labels the client a drug abuser. What is the nurse demonstrating?

Ethnocentrism Ethnocentrism is the tendency of a person to hold his or her own beliefs superior to those of other people. It causes biases and prejudices in regard to people from other groups. This practice is transmitted by cultural groups from one generation to another. In multiculturalism, two cultures coexist and are accepted by the individual. In a cultural encounter, part of cultural competence, a nurse engages in cross-cultural interactions for effective communication. Cultural imposition occurs when a nurse or health care provider ignores the differences between his or her own culture and others and imposes his or her beliefs on people of other cultures. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly and see whether it completely covers the material asked by the question; and (3) narrow the choices by immediately eliminating answers that you know are incorrect.

Which professional standard does the nurse feel is most important for critical thinking?

Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Arrange the order of steps involved in the evidence-based practice process.

Evidence-based practice is a problem-solving approach that integrates the conscientious use of best evidence in combination with a clinician's expertise, client preferences, and client values to make decisions about client care. First, the nurse should ask a clinical question and collect the most relevant and best evidence. Then, the nurse critically appraises the gathered evidence and integrates the evidence with his or her clinical expertise along with the client's preferences and values to make a decision or change. Then the nurse evaluates the practice decision or change and shares the outcomes of the evidence-based practice changes with his or her team.

Which of these programs is least likely to focus on medication delivery process modification?

Experimentation Research Experimental research is least likely to focus on medication delivery process modification. Quality improvement, evaluation research, and performance improvement are all likely to focus on medication delivery process modification in order to make the process better for the client.

Educator

Explain concepts and facts about health, describe the reason for routine care activities, demonstrate self-care activities and reinforce learning

Do's for applying heat/cold therapy

Explain sensations to be felt; report changes immediately; provide timer and call light; look up safe temps

The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers the client his morning blood pressure medication, he refuses to take it. What action should the PN take?

Explain the importance of routine use of antihypertensives.

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies?

Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

What critical thinking skill is applicable when knowledge and experience is used to care for clients?

Explanation When the nurse is using his or her experience to care for clients, the skill called explanation is involved. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer?

False reassurance A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

Which intervention provides confirmation of nasogastric tube (NGT) placement before NGT feedings are started?

Flat plate x-ray of the abdomen.

Sims' position

Flexion of the hip and knees in a side-lying position; used to examine the rectal area and if a female is unable to assume the lithotomy position

An older client who is unable to swallow is receiving continuous nasogastric tube (NGT) feeding. Before administering medication through the NGT, what action should the practical nurse (PN) implement?

Flush the feeding tube with water.

Protective environment

Focuses on clients w/ transplants or gene therapy; positive airflow (>12 exchanges/hour).

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.

Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary. Correct Answer: A

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. What is the muscle functionality of the client?

Full range of motion with gravity In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good).

Which factor is used to assess the quality of health care provided to a client?

Functional health status of client after discharge Health care providers determine the quality of care provided to the client by measuring outcomes that show how a client's health status has changed. One method of measuring the quality of health care provided to the client is the functional health status of the client after discharge. The nursing staff should take necessary fall prevention measures for the client; however, this is not a measurable outcome. All health care personnel should practice hand hygiene to prevent infection, which is a quality measure, not an outcome of health care. Teamwork and coordination among health care personnel is important to provide efficient health care to the client. It is not an outcome of health care.

Language barriers

Get medical interpreter

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Correct Answer: C

Which type of theory is the Neuman systems model?

Grand Theory Neuman systems model is an example of a grand theory that provides a comprehensive foundation for scientific nursing practice, education, and research. Theories related to growth and development are descriptive theories. Prescriptive theories address nursing interventions for a phenomenon, describe the condition under which the prescription occurs, and predict the consequences. Mishel's theory of uncertainty is a prescriptive theory. Middle-range theories tend to focus on a specific field of nursing. Mishel's theory of uncertainty in illness is a middle-range theory.

For several days after her husband's death, a client who is admitted with acute depression repeats over and over, I should have made him go to the doctor when he said he didn't feel well. Which descriptor should the practical nurse use to document the client's feedings?

Guilt.

A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what?

Hand-washing Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

primary intention

Healing process: ?? ?? is a wound that is closed

secondary intention

Healing process: ?? ?? is where the wound edges are not approximated

tertiary intention

Healing process: ?? ?? is where the wound is open for several days

A family member of a dying client asks the practical nurse (PN) if the client knows the family is at the bedside. The PN explains that which of the five senses persists the longest during the dying process?

Hearing

Caregiver

Help patient maintain and regain health, manage disease and symptoms, and attain a maximal level function and independence through the healing process

A male Native American client with tuberculosis is visiting a health care clinic for follow up treatment. During the interview, the practical nurse (PN) notices that the client keeps his eyes on the floor and does not make eye contact. How should the PN interpret this client's behavior?

His culture finds sustained eye contact rude or disrespectful.

Which action should the practical nurse (PN) implement to help a male client cope with his fear as he approaches death?

Hold the client's hand and tell him he is not alone.

interventions

I of SOAPIE

Measuring intake and output

I-O= Total; when you flush a GI tube, have an IV running, or wash the perineum, yo have subtract this from your output. Check I&O every 8 hours. Weight can tell if fluid retention

Always instruct patients to prescribe topical medication when

after showering or bathing because damp skin absorbs better

Presbycusis

age-related hearing loss

ethnicity

an individual's identification of self as part of an ethnic group

Which nursing process involves delegation and verbal discussion with the healthcare team?

Implementation The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.

A Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.

C Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.

In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

A Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day

Presence of yellow purulent drainage during a wound dressing change means

Indicative of infection and health care provider must be notified prior to any other actions

Chain of infection

Infectious agent/pathogen --> reservoir/source for growth --> portal of exit from reservoir --> mode of transmission --> portal of entry to host --> susceptible host

Describe the nurse's legal responsibility when asked to perform a task for which he or she is unprepared.

Inform the health care provider or physician or person asking the nurse to perform the task that he or she is unprepared to carry out the task; refuse to perform the task

What type of procedures should be assigned to professional nurses?

Inform the health care provider or physician; record that the health care provider or physician was informed and the health care provider's or physician's response to such information; inform the nursing supervisor; refuse to carry out the prescription

s/e of antidepressants drugs

anticholinergic effects, postural hypotension

According to Erikson's theory of psychosocial development, which opposing conflicts is an older adult likely to face?

Integrity vs. despair According to Erikson's theory of psychosocial development, an older adult is likely to face the opposing conflict of Integrity versus Despair. An infant in the age group between birth and one year old is likely to face the opposing conflicts Trust versus Mistrust. A young adult is likely to face the opposing conflicts Intimacy versus Isolation. School-aged children between the ages of 6 and 11 years are likely to face the opposing conflicts Industry versus Inferiority.

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.

Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority. Correct Answer: C

74.A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown.

Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. Correct Answer: A

Indirect contact transmission

Involves transfer of an infectious agent through a contaminated intermediate object

An 80 year old male client who has arthritis and is having difficulty walking, tells the practical nurse (PN), "It's awful to be old, It seems as thought every day is a struggle. No one cares about an old person." What is the best response for the PN to provide?

It sounds as though you're having a difficult time. Tell me about it.

What sounds represent blood pressure noises?

Korotkoff's sounds (1st-systolic, 4th-diastolic)

What breathing is noted with diabetic ketoacidosis?

Kussmaul's (trying to get rid of CO2)

lean toward the client

L of SOLER (listening skills) ?? ?? ?? ??

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?

Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident?

Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the adequate functioning of equipment. The hospital shares responsibility for safe, functioning equipment.

Penrose drain

Lies under dressing; pin placed in drain to prevent it from slipping into the wound

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C

Feminine ethics

Looks at social issues; looks to the nature of relationships for guidance of processing ethical demands

Hypokalemia

Low K; normally 3.6 to 5.2 mmol/L; lower than 2.5 mmol/L can be life-threateningin

nausea dizziness headache fatigue

Low O2 can cause ??, ??, ?? and ??

Prone position

Lying on stomach

phenothiazines cause photosensitivity so client must wear protective clothing and sunglasses

MAO inhibitors require dietary restrictions to prevent hypertensive crisis

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?

Macule While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification. Correct Answer: B

Maslow's- Love & Belonging

Maintain support systems, protect from isolation

79.When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame.

Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed. Correct Answer: B

nurse-client anxiety

anxiety is contagious, nurse needs to asses on anxiety level and remain calm. it helps gain control, decrease anxiety, and increase feelings of security

The practical nurse (PN) is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. what nursing action should the PN take?

Mark the outlined area of drainage with date, time and initials.

Specific gravity

Measure of dissolved solutes in a solution; an increase in fluid intake dilutes and makes urine lighter as it approaches 1.000; low fluid intake or fluid loss (diarrhea or vomiting) darkens urine and makes the specific gravity rise

Which technique should the practical nurse (PN) use to most accurately assess a client's baseline blood pressure during a routine health examination?

Measure the pressure in each arm while the client sits with the arm supported at heart level.

Zinc

Meats, seafood and whole grains

Oxygen flow meter

Meter that controls the amount of oxygen when using a nasal cannula or mask

Calcium

Milk, cheese, dark green vegetables, dried figs, soy, and legumes

Phosphorus

Milk, liver, legumes, fish, and soy

Accountability

Moral concept that involves acceptance by a professional nurse of the consequences of a decision or action

Advanced Practice Registered Nurse (APRN)

Most independently functioning nurse; has masters degree in nursing

NLN

National League for Nursing; sets standards for excellence and innovation in nursing education

When there is a dislodged saline lock do you need to notify the physician?

No just prepare to insert a new one during next meds

Which mask can deliver 100% oxygen?

Non-rebreather

Noctural emissions

Normal

A nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect?

Normal Finding The client's nail, which has a slight convex curve at the angle from the skin to nail base of about 160 degrees, is normal. In clubbing, there is a change in the angle between the nail and the nail base that is larger than 180 degrees. Paronychia is the inflammation of the skin at the base of nail. Koilonychia is the concave curves on the nail.

64 75

Normal room temperature is between ??F and ??F

Where should a blood pressure cuff NOT be placed?

Not on site of IV, fistula, mastectomy

A client is prescribed humidified oxygen via face mask, but the water canister for the oxygen is empty what should the nurse do?

Notify respiratory therapy to refill the water canister or add water to canister if available, DO NOT SHUT OFF THE OXYGEN the client needs it

Despite the procedure being discussed with the patient the evening before, your patient asks you what is going to happen what should the nurse do?

Notify the surgeon so that the client can receive info about the procedure

disaster

any human-made or natural event that causes destruction and devastation that cannot be alleviated without assistance

A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do?

Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.

objective findings

O of SOAP ?? ??

observe an open posture

O of SOLER (listening skills) ?? ?? ?? ??

Nonmaleficience

Obligation to "do no harm"; prevent harm

Justice

Obligation to be fair; equal treatment to all clients

Which intervention should the practical nurse (PN) use to prevent obstruction of a gastric feeding tube?

Obtain a prescription for a liquid drug form instead of crushing tablets.

The practical nurse (PN) is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement?

Obtain a soft-bristle brush for the client.

Logrolling

Obtain assistance; place pillow between client's knees (prevents tension on the spinal column). Cross client's arms (prevents injury).

A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the practical nurse's priority intervention?

Obtain orthostatic blood pressures.

A-R

apical-radial pulse

When caring for a patient with TB what should you do when you enter the client's room

apply a respirator prior to entering

the most important s/s of depression are a depressed mood with a loss of interest in the pleasures in life

the client has a sustained loss

71.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A

C Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time.

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

Stage 2 Hypertension

Over 160/ over 100

Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client's leg?

Overlap turns of the bandage equally.

What orders would you expect if a patient had low H&H?

Oxygen and PRBCs (packed red blood cells)

planning

P of SOAP

A patient with COPD has chronic elevation of _____and has lost sensitivity to it as a drive to breathe

PaCO2

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B

Incident pain

Pain that is predictable and elicited by a specific behaviors such as physical therapy or wound dressing changes

Spontaneous pain

Pain that is unpredictable and not associated with any activity or event

End-of-dose failure pain

Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?

Paresthesias Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

What should the community nurse teach about the risk of adolescent pregnancy?

Risk for premature birth The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what?

Perception of change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

A theory contains a set of components such as concepts, definitions, assumptions or propositions. What do these components help to explain?

Phenomenon A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon. The domain is the perspective of a profession. A paradigm is a pattern of thought that is useful in describing the domain of a discipline. Environment or situation includes all possible conditions affecting clients and the settings in which their health care needs occur.

Code of ethics

Philosophical ideals of right and wrong that define the principles you will use to provide care to your patients

The healthcare provider prescribes a cleansing enema for an adult prior to bowel surgery. Which intervention(s) should the practical nurse implement to ensure adequate bowel cleansing? (Select all that apply)

Place the client on the left side in Sim's position. Use enema fluid that is near 105 F (40.4 C). Instill 500 mL to 1,000 mL fluids slowly. Raise the enema container 20 inches above anus. Encourage the client to retain fluid 10 to 15 minutes.

An older client who complains of dry mouth is having trouble swallowing pills. What action should the practical nurse take when administering an enteric-coated tablet?

Place the whole tablet in a spoonful of pudding.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D). Correct Answer: B

64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk.

Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. Correct Answer: A, B, C, E

The practical nurse (PN) is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the client's comfort?

Preform oral hygiene frequently.

A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. he client expresses fear about becoming addicted to these drugs. What information should the practical nurse (PN) provide?

Prescribed opiates for cancer pain relief improve quality of life.

the best time for interaction with a client is at the completion of the performed ritual

the client's anxiety is lowest at this time and its an optimal time for learning

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission?

Primary Nurse The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or healthcare provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

Cultural assimilation

Process in which individuals from a minority group are absorbed by the dominant culture and take on the characteristics of the dominant culture

Value clarification

Process of becoming conscious of and identifying ones values

Acculturation

Process of learning norms, beliefs, and behavioral expectations of a group other than one's own group

Delegation

Process of transferring a selected nursing task in a situation to an individual who is competent to preform that specific task

The nurse at a community healthcare center focuses on providing primary preventive care. What is the focus of primary preventive care?

Promoting health in healthy individuals Primary prevention precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.

Confidentiality

Protection of personal health information

HIPAA

Protection of personal health information

A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client's oxygenation?

Provide oxygen during rest periods between suctioning.

patient with cellulitis is experiencing edema and pain of the extremity how should you assist

apply warm compresses, leg elevation, skin hydration with topical creams, application of warm and cold compresses.

69.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate.

Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. Correct Answer: B

What does PASS stand for?

Pull the pin Aim for the base of the flames Squeeze handle Sweep

Which growth and developmental characteristic should the practical nurse (PN) consider when discussing spirituality with an adolescent client?

Questions religious practices and values.

relax

R of SOLER (listening skills) ??

Who can perform catheter insertions?

RNs. UAP can only position patient, report discomfort, report characterization of urine

State boards of nursing

Reason for existance is public protection; regulation of nursing care

Acetaminophen is prescribed for an unconscious client with a temperature of 104 F. Which route should the practical nurse (PN) plan to administer this medication?

Rectal.

Skin break down

Related to shear, friction, altered LOC, impaired mobility/sensory perception and moisture; lead to ulcers

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

Relieve the client's discomfort Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Correct Answer: B

After a patient bathes you notice the saline lock on their arm is partially separated from the skin and the patient says the insertion site is sore what should you do?

Remove saline lock and prepare to insert a new one at a different site prior to the next medication dose

An older male client tells the practical nurse (PN) that his religion does not permit him to bathe daily. How should the PN respond?

Request that the client clarify his religious beliefs about bathing.

What does RACE stand for?

Rescue the patient Activate alarm Confine or contain Extinguish

Which component of decision-making refers to the duties and activities an individual is employed to perform?

Responsibility Responsibility refers to all duties and activities an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

What nutritional information should the PN provide a client with heart failure (HF)?

Restrict dietary sodium intake.

The client is receiving a continuous tube feeding. While checking the gastric residual volume, the practical nurse (PN) aspirates 150 mL of gastric contents. What action should the PN take?

Return all the aspirated contents to the stomach followed with water and consult the agency policy.

6 Rights of Medication Administration

Right dose, right time, right patient, right route, right documentation, right medication

evidence-based practice

approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care

lifestyle

Risks such as drug and alcohol abuse are considered ?? risk factors

Which information should the practical nurse provide a client who is selecting a site for self-injection of insulin?

Rotate sites within the same location for a week before choosing a new location.

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what?

Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

The practical nurse (PN) is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client?

Soybeans

older male patient with mild aching pain and occasional swelling in the groin area whats the next assessment step

ask client to strain while holding his breath, this will make a hernia more obvious

what should you do first with a patient with a rapidly decreasing level of consciousness

assess airway and breathing

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed. Correct Answer: D

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C

Which of the following is a description of the percussion technique?

Tapping the skin with the fingertips to vibrate underlying tissues Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves using the sense of touch to assess and collect data. Generally during an inspection, the nurse should carefully look for abnormal findings.

B Rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

children experience depression, which presents as headaches, stomachaches, and other somatic complaints

assess suicide risks, especially in the adolescent

what action should the nurse take in a psychiatric situation when the client describes a physical problem?

assess. example: if a client has schizophrenia complains of chest pain take their blood pressure

Hearing a pop inside the ears for a patient with otitis media

the eardrum perforated

65.What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing.

The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). Correct Answer: A

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Correct Answer: B

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding. Correct Answer: A

registered nurse is educating a nursing student about the stages of changes in a client's health behavior. Which statement describes the stage of contemplation?

The client considers a change within the next 6 months. In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time and begins 6 months after action has started and continues indefinitely, the client has reached the maintenance stage.

Which assessment finding is associated with depression?

The client has islands of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

A nursing student is recalling the order of priority for giving consent to perform an autopsy in cases where a medical examiner review is not needed. Which person receives the highest priority for giving consent?

The client in writing before death If a medical examiner's review is not necessary, the highest priority is given to the client. The client may provide the consent in writing before death. If the client or the surviving spouse is unable to give consent for the autopsy, a surviving child may be requested to give consent. The surviving parent may give consent for an autopsy if the client, the surviving spouse, and the surviving child are unable to do so. In case the client has not provided written consent before death, the nurse may obtain consent from the surviving spouse.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.

The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C). Correct Answer: D

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct Answer: B

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct Answer: B

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. Correct Answer: B

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.

The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high. Correct Answer: A

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy. Correct Answer: B

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy. Correct Answer: B

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.

The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct Answer: A

What are the steps of evidence-based practice (EBP) in order?

The first step in EBP is to ask the relevant clinical question. The second is to collect the most relevant and best evidence. After the collection, critically appraise the evidence gathered. Then integrate all the evidence into one's clinical expertise and client preferences and values to make a practice decision or change. Then evaluate the practice decision or change. The last step is to share the outcomes of EBP changes with others.

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). Correct Answer: C

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of sensory and motor functions. Correct Answer: C

D Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name.

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D). Correct Answer: C

B Rationale: Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

Ethics

The ideals of right and wrong; guiding principles that individuals mat use to make decisions

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D). Correct Answer: B

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D). Correct Answer: B

A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?

The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C

The practical nurse (PN) is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in this client?

The lips and mucous membranes of a client with dark skin are dusky in color.

A client with history of heart disease has an enlarged liver and ascites how can you distinguish between a cardiogenic or hepatic cause

assessment of hepatojugular reflux, heart failure can cause enlargement of the liver ascites formation this reflux supports right heart failure

Positive Homan's sign

associated with deep vein thrombosis

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct Answer: B

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A). Correct Answer: A

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction?

The nurse adjusts the bed and asks if the client is comfortable The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse's willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse should close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary healthcare provider's imminent visit.

B Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.

diastolic

atrial and ventricular relaxation of which allows the chambers of the heart to fill with blood

D Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.

D Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.

B Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns

Which nursing action indicates that the nurse is actively listening to the client?

The nurse interprets what the client is saying and reiterates in his or her own words. The nurse is listening actively if he or she is able to take in what the client says. A nurse who is listens attentively interprets and reiterates what the client is saying in his or her own words. A nurse who states his or her own opinions when the client is speaking is being judgmental. A good listener should be able to reach out by exchanging his or her own stories with the client. If a nurse reads the client's health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage?

The nurse is able to identify the basic principles of nursing care through careful observation. According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

D Rationale: The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential.

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."

used to treat symptomatic bradycardia

atropine

manic clients can be very caustic toward authority figures

avoid arguing or becoming defensive

buddhist and hindus

avoid meat and meat by products

B Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months

D Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.

A Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level

B Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28

B Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."

B Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

A Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.

D Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse.

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.

C Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.

individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not vomited and is absorbed, cardiotoxicity may occur and cause conduction disturbances, cardiac dysrhythmias, fatal myocarditis, and circulatory failure

because heart failure is not usually seen in this age group, it is often overlooked. assess for edema and listen to breath sounds

Which characteristic indicates that nursing is a profession?

The nurse is required to follow a code of ethics. Nursing is a profession because it follows a code of ethics, which are the philosophical ideals of right and wrong that define the principles the nurse uses to care for the clients. Nursing is not just a collection of specific skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner. Nursing is a profession because nurses have autonomy in decision making and practice in accordance with the state and federal laws and regulations. Nursing is a profession because its members must not only possess basic nursing education but extended education to explore new methods of health care.

D Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.

C Rationale: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"

.A Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider

B Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.

Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D). Correct Answer: B

B Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL

The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL

A, D Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

Which statement is true for collaborative problems in a client receiving healthcare?

They are identified by the nurse during the nursing diagnosis stage. The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented. Correct Answer: D

72.A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again.

The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. Correct Answer: D

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). Correct Answer: A

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). Correct Answer: A

B Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

D Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.

C Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A

Identify nursing/medical interventions that prevent postoperative paralytic ileus.

a. Early ambulation b. Limiting use of narcotic analgesics c. NG tube decompression

A Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.

77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa.

The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Correct Answer: C

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.

The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. Correct Answer: A

88.What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation.

The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. Correct Answer: B

A client is receiving a daily prescription for furosemide (Lasix) 40 mg PO, but is unable to swallow. The practical nurse (PN) should consult with the healthcare provider about which component of the prescription?

The route of administration.

Common causes of fluid volume deficit:

a. Gastrointestinal causes b. Vomiting c. Diarrhea d. GI suctioning e. Decrease in fluid intake f. Increase in fluid output such as sweating g. Massive edema h. Ascites

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction?

To client from outside resources Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D

78.The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.

To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Correct Answer: B

Which intervention reflects the nurse's approach of "family as a context"?

Trying to meet the client's comfort In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat. Correct Answer: D

cyanosis

blueness or duskiness of the skin due to lack of oxygen and excess carbon dioxide

C Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Correct Answer: D

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Correct Answer: D

How should darker skinned individuals be assessed for skin breakdown?

Use natural/halogen light; will appear darker than surrounding tissue with purplish/bluish hue; have initial warmth with coolness as tissue devitalizes; may appear taut, shiny, scaly

Evidence-based practice

Use of current best evidence from nursing research, clinical expertise, practice trends and patient preferences to guide nursing decisions about care provided to patients

Which action should the practical nurse (PN) implement when supporting an older client who is afraid of dying?

Use open-ended questions to encourage the client to share feelings.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B

The practical nurse (PN) is preparing to reconstitute a drug from powder for for IM administration. Which step should the PN implement first?

Verify the drug with the medication administration record (MAR).

The practical nurse is administering scheduled morning medications to a client who states, I haven't seen that pill before. Are you sure it's correct? Which action should the PN take?

Verify the prescription before administrating the medication.

A client with gastroenteritis, nausea, and vomiting is currently on Nothing by mouth (NPO) status. The healthcare provider prescribes oral intake to be advanced as tolerated. Which fluid should the practical nurse offer first?

Water.

85.What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D). Correct Answer: B

Cheyne-stokes respirations

breathing characterized by deep breathing alternating with very slow breathing or apnea, indicative of brain damage, often precedes death.

B Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall.

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

C Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.

66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions.

When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. Correct Answer: D

D Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.

C Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

D Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it.

When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

B Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.

List the six modalities that are considered noninvasive, nonpharmacological pain relief measures.

a. Heat and cold application b. TENS c. Massage d. Distraction e. Relaxation techniques f. Biofeedback techniques

What six factors should the nurse include when assessing the pain experience?

a. Location b. Intensity c. Comfort measures d. Quality e. Chronology f. Subjective view of pain

List three systems that maintain acid base balance.

a. Lungs b. Kidneys c. Chemical buffers

B Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse's instructions are understood accurately by the client.

Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions.

A Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement

C Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.

D Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.

A Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.

D Rationale: Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter.

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection

D Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

A, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

A Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications.

What areas of care are important for end-of-life care?

a. Pain b. Dyspnea c. Anxiety d. GI symptoms e. Psychiatric symptoms f. Spirituality g. Support for family caregivers h. Family support during bereavement period

Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included?

a. Respiratory activities: coughing, breathing, use of spirometer b. Exercises: range of motion, leg exercises, turning c. Pain Management: medications and splinting d. Dietary restrictions: NPO evolving to progressive diet e. Dressings and drains: orientation to recovery room environment

secondary intention

Wound resulting from surgery causing tissue loss is considered ?? ?? (healing process)

tertiary intention

Wound that is left open to monitor for infection is considered ?? ?? (healing process)

75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration.

Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. Correct Answer: A

Immediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present.

You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions?

You will need to apply them in the morning before you lower your legs from the bed to the floor. Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

mitral stenosis you'd hear

a louder S 1

A week old full-thickness wound is healing well if it appears

a pink wound bed, soft and bumpy appearance and bleeds easily (pink soft and bumpy is granulation tissue and it bleeds easily because it is highly vascularized)

The nurse is attempting a fingerstick on a diabetic patient and is having difficulty obtaining a suitable drop of blood. Which intervention may facilitate this process?

a warm compress vasodilates

Describe six patient rights guaranteed under HIPAA regulations that nurses must be aware of in practice.

a. A patient must give written consent before health care providers can use or disclose personal health information b. Health care providers and physicians must give patients notice about providers' responsibilities regarding patient confidentiality c. Patient's must have access to their medication records; Providers who restrict access must explain why and must offer patients a description of the complaint process d. Patients have the right to request that changes be made in their medical records to correct inaccuracies e. Health care providers must follow specific tracking procedures for any disclosures made that ensure accountability for maintenance of patient confidentiality f. Patients have the right to request that health care providers and physicians restrict the use and disclosure of their personal health information, though the provider may decline to do so.

Variables that increase surgical risk.

a. Age: very young and very old b. Obesity c. Malnutrition d. Preoperative dehydration/hypovolemia e. Preoperative infection f. Use of anticoagulants (aspirin) preoperatively

Identify three nursing interventions that prevent postoperative urinary tract infections.

a. Avoiding postoperative catheterization b. Increasing oral fluid intake c. Emptying bladder every 4 to 6 hours d. Early ambulation

Identify the five stages of death and dying.

a. Denial b. Anger c. Bargaining d. Depression e. Acceptance

List five nursing interventions to promote adequate bowel functioning for older persons.

a. Determine what is "normal" GI functioning for each individual b. Increase fiber and bulk in the diet c. Provide adequate hydration d. Encourage eating small meals frequently

A registered nurse is teaching a nursing student about the concepts that make up a theory. Which point noted by the nursing student needs correction?

concepts consist of interrelated theories. A theory consists of interrelated concepts. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences

bradypenia

condition where the breathes are abnormally slow and fall below 10 breathes/ minute.

negligence

conduct that falls below a standard of acre; failure to meet a client's needs either willfully or by omission or failure to act

black dots periodically with vision are

considered normal as long as they do not obstruct vision

renal diets

constricts potassium, sodium, protein, phosphous only eat fresh fruits and veggies

diabetic diet

control carb intake

Pain localized at the sternal border that intensifies with palpation is characteristic of

costochondritis which is benign and can be treated with an NSAID to reduce inflammation

low paO2 causes

cyanosis

harm reduction is a community health strategy designed to reduce the harm of substance abuse to families, individuals, community, and society

denial and rationalization are the two most common coping styles used for substance abuse

lysis

destruction due to a specific agent; gradual recovery from disease or an elevated temperature that gradually returns to normal

patients taking birth control are at a higher risk for what during post op

development of thrombi

sphygmomanometer

device used is conjuction with a stethoscope to measure blood pressure, consisting of a cuff and bulb

DBP

diastolic blood pressure

pulse pressure

difference of systolic minus diastolic pressure

You are following a critical pathway for the client recovering from a total hip replacement. According to the pathway he should be moved to rehab on day 3, but he has a postop wound infection and has not progressed properly according to the pathway what should you do?

document a variance on the pathway and reason why the pathway is not being followed.

basic communication principles

establish trust, nonjudgemental attitude,active listening, offer self, accept client's feelings, validate client's statements, matter of fact approach

internal disasters

events that occur within a health care agency

Potent topical corticosteroid to be applied to scalp to treat psoriasis, the scalp should not

ever be cleaned with alcohol prior (however side effects do include thinning of skin and this medication should not ever be used more than 2 days in a row)

kyphosis

excessive convexity of the thoracic spine

stereotyping

expectation that all people within the same racial ethnic, or cultural group act alike and share the same beliefs and attitudes

ausculation

externally listening to sounds from within the body to determine abnormal conditions, as in blood pressure

What legal complications might a nurse face for using a restraint without a legal warrant on a client?

false imprisonment If a nurse uses restraints without a legal warrant on a client, he/she may be charged with false imprisonment. Libel is the written defamation of character. Negligence is any conduct that falls below the standard of care. Malpractice is a type of negligence that is regarded as professional negligence.

physical assessment and nutritional support are a priority, the physiological implication are great. nursing interventions should increase self-esteem and develop a positive body image.

family therapy is most effective because issues of control are common in these (eating disorders.) therapy is usually long term

patient with history of chronic alcohol abuse and cirrhosis what else do you expect to find

firm, well defined edge felt at the fingertips in the right upper quadrant during inspiration (a soft edge is healthy);

A patient is prescribed 500 mg of a med every 8 hrs. The med comes as 250 mg in 10 ml. How many ml will the patient receive in 24 hours?

first do 10ml/250mg x 500mg and you get 20 ml then do 20ml/dose x 1dose/8hrs x 24 hrs and you get a total of 60 ml in 24 hours

newborn with dysplasia of the hips

flex hips to 90 degrees and gently adduct thighs from midline while applying downward and lateral pressure (barlow maneuver)

pureed diets

food is blended in blender pulp like mixture

full liquid

foods that melt pulp is okay creamed soups ice cream

Solutions labeled as opened within 24 hours can be used when

for clean procedures but not sterile procedures

TA

forehead

mechanical soft diets

ground meat or soft cooked foods (difficulty chewing)

what type of therapy is used with chemically dependent clients?

group therapy

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B

hairy leukoplakia

hairy white plaques on the lateral side of the tongue caused by HIV

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?

he client's pain is 7 on a scale of 1 to 10. Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client's health status. The client's weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.

Patient with increased intracranial pressure what position should you put them in

head of bed raised to 30 degrees with head in neutral midline position, this will promote cerebral venous drainage and help lower the intracranial pressure (ICP)

resonance

heard over the lungs

Bright red patch in the internal lateral side of the left eye with no other abnormalities what is important to assess

history of trauma because a red patch is a manifestation of a subconjunctival hemorrhage

tracheostomy care

humidification of the oxygen source is required at all times to prevent damage to the respiratory mucosa and keep secretions liquefied. Area around the stoma should be cleaned with normal saline only and catheters for suctioning should not exceed 50% of the lumen. Cuff pressure should range between 15-30 and should be measured twice daily to prevent damage to respiratory tract when pressure is too high or air leakage when pressure is too low

s/e MAO inhibitors

hypertensive crisis

Lack of judgment would be

if a patient was taking other things without permission and thinks that is okay

in child abuse, the nurse is responsible for reporting all suspected cases of abuse

in intimate abuse, its the adult's decision and the nurse should be supportive

what behaviors are expected during withdrawal?

in the alcoholic DT's occur 12-36 hours after the last intake of alcohol

confidentiality

in the health care system, refers to the protection of privacy of the client's personal health information

Corticosteroids

increase serum glucose levels and inhibit the inflammatory response

A person normally uses _____ as the drive to breathe

increased PaCO2 levels

hepatomegaly

increased area of dullness to percussion either in midclavicular line of RUQ or extending in the LUQ

common physiological responses to anxiety

increased heart rate, and blood pressure, rapid shallow respirations, dry mouth, tight feeling in throat, tremors, muscle twitching, anorexia, urinary frequency, palmar sweating

inhaler medication should be

inhaled through the mouth simultaneously

patient comes in with right sided abdominal pain but normal assessment values what should you do

inspect stool sample for presence of clay color or fatty streaks

stethoscope

instrument used to hear internal sounds

leadership

interpersonal process that involves influencing others (followers) to achieve goals

Acrocyanosis in infants

is a common finding that can be caused by crying or as a result of decreased body temperature

Positive Brudzinski's sign

is flexion of the hips and knees when the neck is flexed in a client with meningitis

it is difficult for an elderly person to admit abuse for fear of being placed in a nursing home or being abandoned

it is imperative to establish a trusting relationship with elderly client

what medication can the nurse expect to administer to chemically dependent clients?

librium or ativan, antabuse for alcohol abuse

don't argue with a client about the delusions.

logic only increases a client's anxiety, so be matter of fact and divert delusional thought to reality

What technique should be used to reposition a client with spinal injury or recovering from spinal surgery

logrolling with other staff members to assist

osteomalacia

look at vitamin D levels

Patient with positive romberg sign

loss of balance when standing with eyes closed

S2 is

louder than S1 normally

cardiac diets

low cholesterol low sodium less meat

where should a manic client be place on the unit?

make every attempt to reduce stimuli in the environment, place client in quiet part of the unit

MAP

mean arterial pressure

aspiration

means whatever the object is will enter the respiratory tract rather than the stomach

atypical antipsychotics drugs are also indication for mania

monitor serum lithium levels carefully. 0.-1.5 is therapeutic level, blood should be drawn every 12 hours after last dose

accountability

moral concept that involves acceptance by a professional nurse of the consequences of a decision or action

PaO2

more than 80

Anti-depressants can actually help with

neuropathic pain (such as peripheral neuropathy in the legs of a patient with type 2 diabetes)

islamic

no alcohol, pork or caffeine

kosher diet

no pork shellfish blood cant combine meet and dairy

A client with carbon monoxide toxicity requires oxygen therapy which oxygen delivery system should you use

non-rebreather mask (nasal cannula does not deliver high enough concentrations of oxygen)

what activities are appropriate for a manic client?

noncompetitive physical activities that require the use of large muscle groups

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?

nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

what basic needs take priority when working with chemically dependent clients?

nutrition is a priority, alcohol and drug intake has superseded the intake of food for these clients

oral

of or perrtaining to the mouth

Patient with left-sided weakness you should stand

on affected side for support

when taking lower extremity bp where should the cuff be placed

on the thigh and have the popliteal exposed so you can auscultate the popliteal pulse

O

oral/mouth

Gate control theory

pain impulses travel from the periphery to the gray matter in the dorsal horn of the spinal cord along small nerve fibers

to asses for crepitus in the knee joint you should

palpate

Japanese culture and pain

people often show a stoic response to pain, so it is important to look for physical clues

ethnic group

people within a culture who share characteristics based on race, religion, color, national origin or language

PO

per os

Technique to determine lung border changes during respiration

percussion of the lower posterior lung fields

2nd cranial nerve

perform snellen chart test (optic nerve)

Assessing a patient with type 2 diabetes how should you assess for foot ulcers

peripheral neuropathy is best assessed with a pin prick test to assess loss of sensation

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse?

sit down next to bed and allow her to cry Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.

nursing intervention for depressed client

sit quietly with the client, offering your support with your presence

orthopnea

sitting or leaning forward to facilitate breathing

Symptoms of sleep deprivation include

slurred speech, flat facial affect and red conjunctiva

CN 1

smell

what levels should be monitored during prolonged NG suctioning

sodium and potassium because of the loss of fluid

Korotkoff's sounds

sound heard when measuring the heartbeat with a stethoscope

koilonychia

spoon shaped nails with a concave shape, they are a manifestation of chronic iron deficiency and yuou should look at a hemoglobin (HB) lab test

a scaly spot on a sun-exposed area that comes and goes and sometimes bleed is associated with

squamous cell carcinoma you should look for fine lines and wrinkles in the skin with rough patches and flat brown marks

Precaution for patient with HIV?

standard because HIV transmission only occurs with contact with blood products and body fluids

If patient is demonstrating sundowning behavior (confused) during evening shifts what should you do

stay with patient and reorient his location

Saline locks must be inserted using which technique

sterile

while endotracheal suctioning a patient you note deceleration of HR what do you do first

stop suctioning and re-oxygenate client (suctioning needs to be limited to 10 seconds to prevent bradycardia from occuring)

When brushing teeth of an unconscious patient if they start to choke you should

suction

Murphy's sign

sudden stop of inhalation in the middle of a breath during deep palpation of the upper right quadrant and is used to diagnose cholecystitis

Placing your hands on the chest of a patient with pneumonia to feel for vibrations would be assessing for

tactile fremitus

The practical nurse (PN) is applying a dry, sterile dressing to a client's abdominal wound. Which allergy should the PN verify with the client?

tape.

farenheit

temperature scale at which water boils at 212 degrees and freezes at 32 degrees.

Cerebral Edema/Cerebral Swelling

use 0.45% normal saline

Excess Fluid Volume

use 5% sucrose in 0.9% normal saline

If no bruit can be auscultated over the fistula site you should

use a doppler

If you are unable to determine if a client has jugular vein distention what should you do

use a tangential lighting

IM injection of 1.5 what location do you use

ventrogluteal because it is preferred site and free of major nerves and can hold large volumes

consent

voluntary act whereby a person agrees to allow someone else to do something

nausea is a common complaint after ECT

vomiting by an unconscious can lead to aspiration. maintain a paten airway

A bacterial infection that has spread to the lymph nodes you would also see

warm and tender lymph nodes

Increased PT/INR can be seen in patients

with hepatic dysfunction, vit. K deficiency or anticoagulation therapy

Abstract reasoning

would be a patient not being able to determine the similarities or differences between two objects

a wound should

wound should be irrigated with normal saline before the culture is taken so the dressing is removed

advance directive

written document recognized by state law that provides directions concerning the provision of care when a client is unable to make his or her own treatment choices; the two basic types of advance directives including an instructional living will and durable power of attorney for health care

Alzheimer medication

you can use atypical antipsychotics. Clozaril is not a front line agent because of side effects. one may also give mood stabilizers, and antianxiety medications