RN Fundamentals Online Practice 2019 A with NGN

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complimentary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which therapy? 1. biofeedback 2. aloe 3. feverfew 4. acupuncture

acupuncture

The Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale is used for clients

aged from 2 months to 7 years old

The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of

an allergic reaction to the blood transfusion

During the ___ of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

anger stage

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? 1. "is your pain constant or intermittent?" 2. "what would you rate your pain on a scale of 0 to 10?" 3. "does the pain radiate?" 4. "is your pain sharp or dull?"

"is your pain sharp or dull?"

Cloudy pupils mean that the client has ...

- cataracts - vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly

The Institute for Safe Medication Practices designates

- nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation - recommends including a space between the dose and the unit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages - "unit(s)" as the correct term for use in medication documentation - either "subcut" or "subcutaneously" as the correct terms for use in medication documentation.

Fluid volume deficit causes...

- tachycardia - increase in hematocrit level due to depletion of extracellular fluid - increase in RR - slows capillary refill

Lacrimal apparatus is

- tear system - a group of glands, sacs and ducts that makes new tears and drains old ones away - lubricates and protects eyes

Creatinine expected reference range

0.5 to 1.1 mg/dL for women 41 to 60 years of age 0.6 to 1.3 mg/dL for men 41 to 60 years of age Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine

BUN expected reference range

10 to 20 mg/dL

DTR technique: triceps reflex

To elicit the expected response of arm extension at the elbow, the nurse should hold the client's upper arm horizontally while allowing the lower part of the client's arm to relax and tap the triceps tendon just above the elbow using a reflex hammer.

For an older adult client, an angle of ___ is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue.

10° to 15°

A protective environment requires at least

12 air exchanges per hour

Sodium expected reference range

136 to 145 mEq/L

Open irrigation technique requires instilling

30 to 40 mL of irrigation fluid

The nurse should use a ___ to perform open irrigation.

30- to 50-mL syringe

___ is the responsibility of nurses to explain their own actions to their clients and employer.

Accountability

___ is a key component of professional nurses' code of ethics. The nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

Advocacy

___ are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles.

Airborne precautions

___ dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. It forms a soft gel when it comes in contact with drainage.

Alginate

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance.

Normal bronchovesicular breath sounds

Characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.

DTR technique: Achilles reflex

To elicit the expected response of plantar flexion of the foot, the nurse should bend the client's ankle slightly backward and tap the Achilles tendon at the ankle just above the heel using a reflex hammer.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1. Verify the client's name on their identification bracelet with the medication administration record. 2. Call the pharmacy to determine whether the client's medications are available. 3. Compare the client's home medications with the provider's prescriptions. 4. Place the client's home medication bottles in a secure location.

Compare the client's home medications with the provider's prescriptions.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? 1. Protective environment 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

Contact precautions

___ dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing.

Transparent

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

___ are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis.

Droplet precautions

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning

During the admission process Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. 1. Examine personal values about the issue 2. Tell the parents that this is a necessary procedure. 3. Inform the parents that the staff does not require their consent 4. Contact a spiritual support person to explain the importance of the procedure

Examine personal values about the issue Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

___ is an agreement by nurses to follow through with promises made to clients.

Fidelity

Moistened ___ promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed.

Gauze

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus

A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nursing use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid

Hydrocolloid

___ dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

Hydrocolloid

___ is fairness in client care delivery, including the distribution of resources and care.

Justice

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

Make sure the client wears a mask when outside her room if there is construction in the area

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? 1. Assist the client into a prone position. 2. Place a sleeve over the top of each leg with the opening at the knee. 3. Make sure two fingers can fit under the sleeves. 4. Set the ankle pressure at 65 mm Hg.

Make sure two fingers can fit under the sleeves.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to measure the client's vital signs every 15 min and report back in 1 hour. Which of the following actions should the nurse take next? 1. Document the provider's statement in the medical record. 2. Complete an incident report 3. Consult the facility's risk manager. 4. Notify the nursing manager.

Notify the nursing manager.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

Obtain an apical heart rate by

Place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer 2. Focus teaching on what the client will need to do in the future to manage his illness 3. Provide the client with written information about the phases of loss and grief. 4. Reassure the client that this is an expected response to grief.

Reassure the client that this is an expected response to grief.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance-stress?

Role overload

A nurse is preparing a change-of-shit report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.

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

Subtract the amount of irrigant used from the client's urine output.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors. Protect the client's airway from cold air, dust, and other airborne particles.

Generally, the nurse should insert the IV peripheral catheter at ___ angle.

a 10° to 30°

A nurse is performing guaiac testing for a client to screen for colon cancer. The nurse should identify that ingestion of which of the following foods can cause a false negative result? dairy products citrus fruits soy products fish with omega-3 fats

citrus fruits Clients should not consume citrus fruits or juices for 3 days prior to guaiac stool testing because vitamin C can produce a false negative result. Should avoid eating red meat for 3 days prior to testing

Aloe is a

complementary and alternative therapy that can help improve disorders and can have wound healing effects.

Feverfew is a

complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew.

Major wound infections require ___ , which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

contact precautions

The Emergency Medical Treatment and Active Labor Act...

directs emergency personnel to provide screening and stabilizing care before discharging or transferring clients to another facility.

Crackles (also called rales) are

discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways.

The Z-track technique involves

displacing the skin laterally or downward prior to administration of an IM injection.

Rhonchi are

dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions

Sick role refers to the

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

A febrile reaction has manifestations of

fever, chills, headache, flushing of the face, and muscle pain.

Role overload refers to

having more responsibilities within a role than one person can manage

O2 readings less than 90% reflect

hypoxemia

Contact precautions are a requirement for clients who have

infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections.

Droplet precautions are a requirement for clients who have

infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

Advance directives include a

living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

The nurse should compare the client's home medications with the provider's prescriptions when performing ___.

medication reconciliation

The nurse should verify the client's ___ when administering medication

name on their identification bracelet

Clients who have a compromised immune system require a ___ .

protective environment

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? 1. regulate the flow rate by aligning the rate with the top of the ball inside the flow meter 2. regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min 3. make sure the reservoir bag of a partial rebreathing mask remains deflated 4. use petroleum jelly to lubricate the client's nares, face, and lips B

regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min

Intubation is a

resuscitative measure the staff should not implement this intervention for a client who declines resuscitation in their living will

Asking the client to rate the pain using the pain scale determines

the intensity of the pain.

When assessing the pain level of an adult.

the nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale

Asking the client whether the pain is constant or intermittent determines

the onset, duration, and pattern of the pain.

Asking the client whether the pain radiates determines

the pain's location.

The Americans with Disabilities Act protects...

the privacy of a client who chooses not to disclose a medical disability

Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine

the quality of the pain.

Water-resistant gowns are only indicated if

there is a likelihood of contact with the client's body fluids

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks,"What would happen if I arrived at the emergency department and had difficulty breathing" which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

Things that stimulate GI motility

- Alcohol - Caffeine - Hot liquids (stimulate peristalsis) - Carbonated beverages - Milk/fruit (simple sugars) - Foods high in fiber

3 tasks the nurse should delegate to an assistive personnel (AP)

- Document the client's vital signs - Measure the client's intake and output - Transfer the client from wheelchair to bed

Teachings for patient who has diarrhea

- Increase intake of high-potassium foods - Eat probiotic foods to help reduce diarrhea - Avoid alcohol - Eat vegetables that are well-cooked and do not have skins or seeds - Eat small meals throughout the day - Avoid caffeine - Avoid drinking hot liquids - Avoid drinking carbonated beverages - Follow a low-fiber diet

Isolation precautions

- Wear an N95 mask when caring for the client - Place a container for soiled linens inside the client's room - Place the client in a negative airflow room - Remove mask after exiting the client's room

Testing visual field

- use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. - clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall

Children 3-5 years RR

20 - 25 / min

HCO3- expected reference range

21 - 28 mEq/L

Potassium expected reference range

3.5 to 5 mEq/L

Newborn RR

30 - 60 / min

Older adult average body temp

35 - 36.1 C (95.9 - 99.5 F)

PaCO2 expected reference range

35 - 45 mm Hg

Oral temp range

36 - 38 C (96.8 - 100.4 F) average: 37 C (98.6 F)

Newborn temp should be between

36.5 - 37.5 C (97.7 - 99.5 F)

The nurse should insert the needle at a ___ angle for a subcutaneous injection.

45° to 90°

The client who has tuberculosis should be placed in a negative airflow pressure room that provides at least

6 to 12 air exchanges per hour through a HEPA filtration system.

pH expected reference range

7.35 - 7.45

PaO2 expected reference range

80 - 100 mm Hg

DTR technique: biceps reflex

To elicit the expected response of arm flexion at the elbow, the nurse should bend the client's arm at the elbow with palms down and tap the biceps tendon using a reflex hammer.

DTR technique: patellar reflex

To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer.

The reservoir bag should inflate

by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale.

Biofeedback is a

complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique.

Fluid overload has manifestations of

cough, crackles heard in bases of the client's lungs, shortness of breath, and distended neck veins.

Potassium levels above the expected reference range of 3.5 to 5 mEq/L, means this client is at risk for...

dysrhythmias

Airborne precautions are a requirement for clients who have

infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.

A critical pathway is an

interprofessional approach to planning all phases of client care.

The nurse should use a transfer report when the client

is moving from one health care area or facility to another.

Role ambiguity occurs when

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

The nurse should call the ___ if the client's medications are not available to administer at the appropriate time

pharmacy

Use of restraints

- Pad the client's wrist before applying the restraints. - evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints - remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting - secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury

Caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves (notes)

- Place client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves - Place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure - Ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate - Set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

- Pupil clarity - Visual fields - Visual acuity

Assess visual acuity by using

- Snellen chart to assess distance vision and a handheld card to assess near vision - Clients who wear eyeglasses should wear them during the assessments. - Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Day 1:Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2:IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. Actions to take...

- Stop the IV infusion and remove the IV catheter - Elevate the client's arm to decrease swelling - Apply heat to hand to reduce swelling and promote comfort

Caring for a client who requires an NG tube for stomach decompression (notes)

- The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration. - The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. - The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client. - Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

Lifting objects (body mechanics)

- The nurse should bend the knees when lifting - The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting - The nurse should use the arm and leg muscles when lifting because they are generally stronger than back muscles. - Stand close when lifting keeps the object in the nurse's center of gravity and decreases back strain from horizontal reaching.

Caring for client's tracheostomy at home

- The nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation - Medical asepsis with clean technique - Never remove outer cannula for cleaning

Administration of oxygen therapy

- The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter. - Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). - Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen.

Client use of cane for mobility

- The top of the cane should be parallel to the client's greater trochanter. - To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. - The client should hold the cane on the stronger side of her body to increase support and maintain alignment - The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? 1. Advocacy ensures clients' safety, health, and rights. 2. Advocacy ensures that nurses are able to explain their own actions. 3. Advocacy ensures that nurses follow through on their promises to clients. 4. Advocacy ensures fairness in client care delivery and use of resources.

Advocacy ensures clients' safety, health, and rights.

___ is the process of comparing a patient's medication orders to all of the medications that the patient has been taking.

Medication reconciliation

Role conflict develops when

a person must assume multiple roles that have opposing expectations.

Friction rub is

a scratching or squeaking sound that persists throughout the respiratory cycle.

For a catheter irrigation, the nurse should place the client in

a supine or dorsal recumbent position for maximal access to the catheter.