ATI Infection Control (Pretest), ATI Fundamentals, ATI FUNDAMENTALS FINAL, ATI Chapter 12-Client safety, ATI - Respiratoryyy, week 5 Fundamentals (ATI) Vital Signs, ATI Chapter 40- Mobility and Immobility, Learning System:RN-Communication, ATI fundam...

non-rebreather mask

-Delivers highest concentration: *95-100%* -10-15 Liters per minute -One way valve prevents room air and client's exhaled air from being inspired -Must not totally deflate during inspiration to prevent carbon dioxide build up

Information Security

-HIPPA: ensures confidentiality of health info -Only those responsible for patient's care may access the medical record. -Do not use patient names on display boards -communication about the pt should happen in a private place or at the nurse's station -password protect electronic records. Do not share passwords. -Do not share pt information with unauthorized people. code system can be used.

Implementation

-Maintain patent airway -Promote Oxygenation -Deep breathing and coughing -Hydration -Medications -Incentive spirometry -Percussion, vibration, postural drainage -O2 therapy

Signs of impending death

-abdominal breathing (cheyne-stokes, apnea, "death rattle") -decreased LOC -decreased muscle tone -mottling of skin, cool extremities -decreased pulse and BP -incontinence, decreased urine output -increased secretions in airways **hearing acuity is NOT decreased during this time

Hypernatremia

-greater than 145 Skin flushed Agitation Low grade fever Thrist

Telephone orders: best practice

-have a second RN listen in -repeat the prescription back -make sure the provider signs the prescription within 24 hr

oral hygiene for unconscious patients

-have suction available -do not put fingers in patients mouth -position patient on side, with head turned towards you. allows oral secretions to drain out, and prevents aspiration

med administration: best practices

-identify allergies to meds prior to administration of any med -question unclear/inappropiate prescriptions (question multiple pills or vials for a single dose) -prepare meds for one patient at a time -only administer meds you prepare -double check high-alert meds with second RN (heparin, insulin) complete incident report for med errors. Do not reference or include report in your charting

patient teaching: incontinence

-maintain toileting schedule -kegel exercises -reduce caffeine, alcohol intake -vaginal cone therapy for stress incontinence -weight reduction program for stress incontinence

Opioid

-moderate to severe pain key side effects: constipation, hypotension, urinary retention, n/v, sedation, respiratory depression. naloxone is the antidote administer around the clock (vs. PRN)

key points of insulin administration

-never mix long-acting insulin (insulin glargine) -if short acting insulin looks cloudy or discolored, do not administer -for insulin suspensions, gently rotate vial prior to administration

Intradermal medication administration

-use tuberculin syringe, 26-27 gauge needle -uses small volume: .01-0.1 ml -insert bevel up at 10-15 degree angle -observe for small bubble. DO NOT massage site

A nurse is caring for a client following a spontaneous abortion. The client is crying and says to the nurse, "I tried to get pregnant for so long. My husband and I wanted this baby so much. Now what will we do?" Which response by the nurse is to be appropriate?

"Are you feeling overwhelmed?"

A nurse is caring for a client who is a victim of rape. The client says to the nurse, "I feel so humiliated. I don't want anyone to know what happened to me." Which of the following is a therapeutic response?

"Are you saying that you are fearful about what others will think?"

A nurse is assessing a client. For which of the following client statements should the nurse use a close-ended question?

"I'm bleeding."

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?" This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it. Do not focus on inappropriate issues or individuals, ignore or dismiss the client's feelings, or disagree with the client by offering unsolicited advice.

A nurse is caring for a client who is postoperative of a colectomy. The clients NG tube is on continuous low suction. The client tells the nurse his throat is ore and asks the nurse when the ng tube is removed. The most appropriate response by the nurse would be?

"When your gastrointestinal tract is working again, in about three to five days, the tube can be removed."

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? A. Side-lying B. Supine C. Semi-Fowler's D. Trendelenburg

C. Semi-Fowler's

A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the patient? A. Bagel with cream cheese B. Fried egg C. Fruit with yogurt D. Wheat toast with peanut butter

D- wheat toast with peanut butter

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting the object? A. Bend at the waist B. Keep his feet close together C. Use his back muscles for lifting D. Stand close to the cabinet when lifting

D. Stand close to the cabinet when lifting

avoid materials

During oxygen therapy use should _____ ________ that generate static electricity, or volatile flammable materials such as: oils, greases, alcohol, ether, an acetone near clients receiving O2.

Patient wants to leave, nurse drugs him

False imprisonment

bomb threat procedure

I will listen for background noises

Knowing that cimetidine decreases metabolism of imipramine hydrochloride, nurse should identify this combo is likely to result in which of following effects?

Increased risk of imipramine hydrochloride toxicity

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.

Inspect, auscultate, percuss, then palpate.

Rn performing abdominal assessment. Identify correct sequence

Inspection, Auscultation, percussion, palpation

Correct order of abdominal assessment of adult client

Inspection, auscultation, percussion, palpation

A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands the tube feeding are needed because the client?

Is unable to swallow food by mouth

Nurse teaching young adult promotion and illness, what indicates client understanding?

It is important to schedule routine healthcare visits, even if feeling well.

MDI/DPI

MDI: shake inhaler DPI: DO NOT shake device hold breath for 10 seconds

MDI/DPI

MDI: shake inhaler DPI: DO NOT SHAKE place mouth around inhaler, take slow deep breath hold breath for 10 seconds take inhaler out of mouth and slowly exhale rinse mouth out after administration if using corticosteroid inhaler to prevent fungal infection

Error Prone Abbreviations

MS, MSO4 for morphine MgSO4 for mag sulfate decimal points without leading 0 (use 0.5 mg, not .5 mg) trailing zero (use 2 mg not 2.0 mg) U,U, IU units qd, q.d. for daily god, q.o.d. for every other day SC. SQ, subq for subcutaneously

empty stomach

Percussion and postural drainage should be done on an ______ _______ to decrease pt discomfort. Postural drainages results in expectoration of large amounts of mucous, pts sometimes ingest part of the secretions. Secretions produce unpleasant taset in mouth which can result in N/V.

What should the RN do first when preparing to provide tracheotomy care

Performing hand hygiene

37. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position. Rationale: The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.

19. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure. Rationale: The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed. Positioning a wheelchair at a 45 degree angle allows the client to pivot, lessening the amount of rotation required. The nurse should assume a wide stance, and instruct the client to lean forward from the hips. The nurse should stand on the client's side that requires the most support.

Nurse on rehab unit is preparing to transfer a client who is unable to ambulate from bed to wheelchair. Which technique should nurse use? Stand on client's strong side Instruct client to lean backward from hips Place wheelchair at 45 degree angle to bed Assume narrow stance

Place wheelchair at 45 degree angle to bed

A nurse is teaching a client with a new colostomy about how to irrigate the ostomy. The nurse realizes the client needs further teaching when the client?

Position the irrigating solution bag 30 feet above the stoma

Parameters for general survey for new client?

Posture, skin lesions, speech

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

Screening groups of older adults in nursing care facilities for early influenza manifestations- Screening older adults who have manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe. Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill. Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill. Finding rehabilitation programs for older adults who have complications from influenza is an example of tertiary prevention, which tries to prevent complications and help people recover from an existing illness.

When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the

Semilunar Valves close -The second heart sound, S2, is generated by the closure of the semilunar valves (the aortic and pulmonic valve) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

Altered breathing patterns

Tachypnea Bradypnea Apnea Kussmauls breathing Cheyne-Stokes Orthopnea Dyspnea

Which is appropriate to include to minimize secretion of breast milk?

Take each prescribed dose right after breastfeeding.

_____ prevention: helping manage long term health problems (Stroke)

Tertiary

Which is conflict with legal guidelines for nursing documentation?

Writing date/time for documentation of care given by another RN

tympany is

a low pitched, drum-like resonance sound

virulence

ability of a pathogen to cause disease

pneumothorax

air in the pleural cavity caused by a puncture of the lung or chest wall

leukotrienes

cause bronchoconstriction, mucous production, and edema of the respiratory tract.

evaluation

compare actual results with planned outcomes, determine next steps

secondary lesions

crust- scab erosion- ruptured vesicle scale- dandruff, eczema fissure- result of too dry/moist skin ulcer- pressure injury

a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include?

current medications

RN is caring for PT with acute renal failure. Most accurate measure of client's fluid status is:

daily weights

nonspecific immunity

defense mechanisms (barriers) in the body that respond immediately to all antigens. Barriers include: skin, stomach acid, mucus, inflammatory response, phagocytic cells.

Urinary tract infections: risk factors

female (close proximity of urethral meatus to anus) foley (indwelling) catheters uncircumcised penis menopause frequent sexual intercourse

Systemic manifestations

fever, malaise, inc in pulse and Resp rate

distribution:

how medication gets from bloodstream to site of action affected by: circulation permeability at destination site protein binding-meds need protein (albumin) to travel to site of action. availability of protein and competition for protein binding sites with other meds can affect distribution

absorption

how meds get from location of administration to bloodstream affected by: route of administration absorption of PO meds is slower because meds must go through GI tract absorption depends on: solubility of med presence of food in stomach GI pH (over adults have higher pH) form of med (liquid, extended release)

Droplet precautions

infections: influenza, pneumonia, pertussis, mumps, sepsis, rubella, bacterial meningitis private room or room with another pt with same infection masks for caregivers and visitors

airborne precautions

infections: measles, varicella (chickenpox), TB private room negative air flow N95 masks

Working phase of the nurse-client relationship

love (if appropriate) stress opportunity

during seizure

lower pt to floor or bed turn pt on side loosen restrictive clothing DO NOT restrain or put anything in their mouth note onset and duration of seizure

primary lesions

macule- flat area of discoloration <1cm (freckle) patch- flat area of discolor >1cm birthmark papule- elevated solid <1cm mole/nevus plaque- "" >1cm psoriasis vesicle- elevated serous filled <1cm herpes, varicella Bulla- """ >1cm blister Nodule- firm deep 1-2 cm -wart Tumor- solid mass, deep >1-2cm (neoplasm) pustule- pus-filled <1cm acne wheal- transient elevated irregular border, edematous, priuritic (insect bite)

body mechanics

need more teaching: line of gravity should fall outside my base of support

sputum specimen collection

obtain in morning, wait 1-2 hrs after they eat,

catheter urine specimen

obtaining a sterile urine sample from a straight or indwelling catheter, using surgical asepsis

cough suppressant

only use when coughing interrupts sleep or resting

skin assessment

pallor : due to circulation issues or anemia cyanosis: due to hypoxia (emergency intervention required) jaundice: due to hepatic dysfunction or RBC destruction erythema (red): due to inflammation, sunburn, rash brown discoloration of extremities: indicates venous insuffiency

what are thrills?

palpable vibration from a murmur or cardiac malformation, measure using palm of hand to check for vibrations

Implementation

perform nursing care, document response to interventions

how to prevent O2 caused fires at home?

place a no smoking sign outside the house and near pts room, ensure electrical equip is in good shape/well grounded, reduce bedding that can generate static electricity (wool, nylon, synthetics) with cotton sheets, keep heating oil or nail polish remover away from oxygen,have a known exit route.

tornadoes for protocol

place blankets over clients in bed move beds away from windows close drapes/shades

Preventing foot drop

place foot board perpendicular to mattress and against soles of patient's feet

sterile field with sneezing pt

place mask on pt

what should patients with wounds be eating?

protein (meat, fish, eggs, poultry, dairy products, beans, nuts, whole grains)

signs of infection

purulent drainage, pain, redness, edema, fever, chills, increased pulse or resp rate, increase in WBC count.

pustule

pus-filled vesicle, < 1 cm (acne)

Stereognosis

put familiar object in pts hand and ask them to identify it

extinguish

put the fire out with fire extinguisher if possible

bioterrorism

putting harmful toxins, bacteria, viruses, pathogens into the air with the intent to cause illness/death.

how often should patients be turned

q1-2hr

urinalysis

random nonsterile specimen

Phone prescription

repeat it back to provider have another nurse listen get signature w/in 24 hrs

rescue

rescue/protect pts in close proximity to the fire if they can walk they can go unattended

optic drops

rest dominate hand on pts forehead drop med into conjunctival sac, without touching eye to dropper apply gentle pressure to nasolacrimal duct for1 minute wait 5 min. between different eye drops

easy symptoms of hypoxemia

restlessness, irritability tachypnea tachycardia increased BP pallor abnormal breathing (use of accessory muscles, nasal flaring, adventitious lung sounds)

a nurse is caring for a client who is receiving fluids through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration?

skin blanching

What to assess for when pt has restraints?

skin integrity offer food/fluids hygiene and bowel elimination vital signs ROM activities

Taking Temporal Temp

slide probe across forehead to hairline touch soft depression behind ear

a nurse is documenting a deep necrotic wound on a pts left buttock. Nurse observes a yellowish, tan soft, stringy area of necrotic tissue formed in clumps + adhering firmly to wound. The nurse should document this as

slough

tumor

solid mass, deep, > 1-2 cm (neoplasm)

high flow systems

supply all oxygen required during ventilation in precise amounts regardless of pts respirations. Venturi mask with large bore tubing

symptoms of fluid volume excess

tachycardia, tachypnea, hypertension, bounding pulses, weight gain, dyspnea, crackles, edema, jugular vein distention

key points for dysphagia

thickin thin liquids check for food pockets tuck chin when swallowing

the right lung has how many lobes

three

illness stage

time when specific symptoms occur

adverse effects of meds: anticholinergic effects "can't see, can't pee, can't sh**, can't spit"

urinary retention, constipation, dry mouth, blurry vision, photophobia, tachycardia pt teaching: increase fiber and fluid intake, wear sunglasses outside

heat stroke pt

will have hypotension

Four components of respiration

1. Movement of air in and out of the lungs 2. Diffusion of O2 and CO2 between alveoli and pulmonary capillaries 3. Transport of O2 and CO2 between the tissues and the lungs 4. Movement of O2 and CO2 between systemic capillaries and the tissues (O2 and CO2 = oxygen and carbon dioxide)

chain of infection

1. toxin/bacteria 2. reservoir (human, soil) 3. portal of exit (blood or respiratory tract) 4. mode of transmission ( contact, droplet) 5. portal of entry 6. susceptible portal

With mass casualties after disaster, who should receive care last?

20 yo with life-threatening multiple traumatic injuries

how much fluid should be consumed per day?

2000mL

A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?

4 - 5

DTRs

4+ brisk, clonus 3+ above average 2+ normal 1+ diminished 0 no response

Fowlers

45-60 degrees good for severe dyspnea and during meals (to prevent aspiration)

normal range of abdom sounds per min?

5-35/min

partial rebreather mask

6-11 L/min

Hypomagnesemia

<1.3 mEq/L causes: GI losses, diuretics, malnutrition, alcohol abuse symptoms: dysrhythmias, tachycardia, hypertension, tremors, seizures, increased DTRs

hypoxic drive

A "backup system" to control respiration; senses drops in the oxygen level in the blood.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the container of medication prior to administration B. Transfer the medication to a medicine cup C. Place the client in a semi-Fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administration

A. Gently shake the container of medication prior to administration Pt. should be in the high-Fowler's position when administering medication.

Which instruction should be followed for a child who is post-op following a tonsillectomy? Encourage frequent coughing to clear congestion from anesthesia. Place a heating pat at child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day. Provide the child with ice cream when oral intake is initiated.

Administer analgesics to the child on a routine schedule throughout the day.

Factors affecting respiratory function

Age Environment Lifestyle Health status Medications Stress

32. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway Rationale: The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them; therefore, the nurse should first assess the client's airway.

Potassium

Alkalosis: K is LOW Acidosis: K is High

A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety med D. Return in 30min to recheck the client's BP

B Perform a pain assessment would be the appropriate action to take next

water soluble vitamins

B vitamins and vitamin C

A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse except to confirm the correct tube placement? A) The tube aspirate has a pH of 7 B) An x-ray shows the end of the tube above the pylorus C) bowel sounds are present on auscultation D) the client reports relief of nausea

B) An x-ray shows the end of the tube above the pylorus

A nurse is initiating a protective environment for a client who is in allogenic stem cell transplant. Which of the following precautions of the nurse plan for this client? A) make sure the clients room has at least six air exchange as per hour B) make sure the client wears a mask out went outside of her room if there is construction in the area C) place the client in a private room with negative pressure air flow D) where an N95 respirator when giving the client direct care

B) make sure the client wears a mask out went outside of her room if there is construction in the area

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A flushing of the skin. B. Inability of the toddler to cry or speak C. Presence of Nausea and mild emesis D. Capillary refill time 1.5 sec

B. Inability of the toddler to cry or speak

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take? A. Use clean technique when suctioning the client's endotracheal tube. B. Use a rotating motion when removing the suction catheter. C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube. D. Suction the client's endotracheal tube every 2 hr.

B. Use a rotating motion when removing the suction catheter. Rationale: The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma.

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirmed the fire, which of the following actions should the nurse take? A) activate the emergency fire alarm B) extinguish the fire C) evacuate the client D) Confine the fire

C) evacuate the client

A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A. Contact the hospitals spiritual services B. Ask him what is making him cry C. Provide quiet times for these moments D. Turn on the television for a distraction

C- provide quiet times for these moments

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include? A. Writing a prescription for morphine sulfate prn B. Inserting a NG tube to relieve pain C. Showing a client how to use progressive muscle relaxation D. Preforming a daily bath after the evening meal. E. Reposition a client every 2 hours to reduce pressure ulcer risk

C- showing a client how to use progressive muscle relaxation D- preforming a daily bath after the evening meal E- repositioning a client every 2 hr to reduce pressure ulcer risk

A nurse is caring for a client who shares the nurses religious background. Which of the following information should the nurse anticipate? A. Members of the same religion share similar feelings about religion. B. A shared religious background generates mutual regard for one another C. The same religious beliefs can influence individuals differently D. The nurse and client should discuss the differences and commonalities in their beliefs

C- the same religious beliefs can influence individuals differently

A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentrism? A. Asking the client what he likes to eat B. Notifying the dietician to complete the menu C. Recommending one's own favorite foods D. Asking the clients family to fill out the menu

C-recommending one's own favorite foods

Wound Healing: Primary Intention

wound edges approximated (sutures/staples). Heals quickly, minimal scarring

Wound Healing: Secondary Intention

wound edges widely separated. Longer healing time, scarring, increased infection risk.

Older Client appears agitated when nurse needs to take dentures away prior to surgery what should the RN respond

"You seemed worried. Are you concerned someone may see you without your teeth?"

A patient drinks 8 oz of water. Which of the following is a correct conversion of the patient's intake?

- 240 mL * One fluid oz equals 30 mL; therefore, 8 fluid oz equals 240 mL.

hich of the following demonstrates the correct use of one of the Six Rights of Medication Administration?

- Administering a patient's medication by the route the provider has prescribed * The Six Rights of Medication Administration are the right medication, the right dose, the right patient, the right route, the right time, and the right documentation. Giving the medication by the route prescribed is indeed an application of the Six Rights of Medication Administration.

You have a handwritten medication order that is difficult to read. Which of the following is the most appropriate action to take to avoid an error in medication administration?

- Call the medical provider for clarification of the order. * There is no other way to be sure about what was intended other than confirming it with the person who wrote the order.

+ orthostatic hypotension

-SBP decrease of more than 20 mmHg when changing position AND/OR -DBP decrease of more then 10 mmHg, with a 10-20 % increase in heart rate

You are giving a patient several PO medications to take. The patient tells you that she can only take one pill at a time. It is appropriate to

- remain at the bedside until you are sure the patient has taken all of the medications. * It is your responsibility to remain with the patient and observe that she has swallowed each medication. It is unacceptable to leave medications unattended for any period of time.

A drug's generic name is the

- same as its nonproprietary name. * A drug's generic name is its nonproprietary or noncommercial name. Each drug has only one generic name. For example, acetaminophen is the generic name for the drug marketed as Tylenol, while ibuprofen is the generic name for the drugs Advil, Motrin, and others.

An uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called

- an idiosyncratic effect. * An idiosyncratic effect is an uncommon, unexpected, or individual drug response thought to result from a genetic predisposition.

Good sleep hygiene practices

- exercise regularly, but NOT within 2 hours of bedtime -limit alcohol, caffeine, and nicotine within 4 hours of bedtime -limit fluids before bedtime -engage in muscle relaxation exercises -have a light carbohydrate snack before bedtime -NO TV or screen time before bed

Med was schedule at 0900. Acceptable admin times?

0905 0840

what is a normal magnesium level?

1.3-2.1 mEq/L

Magnesium levels and function in body

1.3-2.1 mEq/L nerve and muscle function, bone formation. Critical for many biochemical reactions in body.

pressure injury staging

1: non-blanchable erythema (intact skin) 2: shallow ulcer, damage to epi/dermis, pink/red moist wound bed, no slough 3: deeper ulcer (damage to subQ tissue) no exposed muscle, bone, tendon 4: deep, exposed bone/muscle/tendon Unstageable: eschar/slough covers wound bed, cannot determine depth

Hyponatremia

<136 causes: GI loss, diuretics, skin losses, SIADH, edema, hyperglycemia symptoms: tachycardia, hypotension, confusion (elderly), fatigue, n/v, headache

Hypokalemia

<3.5 mEq/L causes: GI losses, diuretics, skin losses, metabolic alkalosis symptoms: DYSRHYTHMIAS, muscle weakness and cramps, constipation/ileus, hypotension

diabetes

>200 mg/dl = hyperglycemia < 70 mg/dl = hypoglycemia

analysis (diagnosis)/ data collection

Custer the collected data identify patterns/trends compare data to expected values

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics

A. Walking briskly

Bradypnea

Abnormally slow respiratory rate, seen in pts who have taken drugs such as morphine or sedatives, metabolic alkalosis, or who have increased ICP.

Postoperative client has been diagnosed with paralytic ileus. When auscultation client's abdomen Rn expects bowel sounds to be

Absent

A nurse is caring for a patient who is post-op with paralytic ileus. Which abdominal assessment is expected? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis

Absent bowel sounds with distention

ABCDE

Airway Breathing Circulation Disability-LOC Exposure

After the client's condition is stabilized, the client says to the RN, "all this equipment is making me nervous. Am I so sick that I need all this? Appropriate nursing response?

All of this equipment can be frightening.

You are assessing a patient's vital signs. the patient has a temp. of 102 degrees F. Which of the following do you expect to find?

An elevated pulse rate -A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

Chest Tube Pulled

An occlusive dressing is used.

Nurse preparing to perform endotracheal suctioning for client. Which are appropriate guidelines for nurse to follow?

Apply suction while withdrawing the catheter Use new catheter for each suctioning attempt Limit suctioning to 2-3 attempts

They have a normal in range BMI

As part of your general survey, you find that your patient has a body mass index (BMI) of 23. From the finding you determine that

AP threatening to put on diaper

Assault

RN is planning intervention for group of clients who are obese. What can Rn do to improve their commitment?

Attempt to develop the client's self-motivation

Nurse inspects abdomen, what next for comprehensive physical exam?

Auscultation

Hypertension

BP readings elevated on 3 several visits over several weeks

Nurse calls surgeon w/ pt's request.

Basic Critical Thinking

Response protocol for botulism as bioterrorism agent. Nurse should prepare based on which of the following?

Botulism can produce paralysis Botulism is toxin found in castor beans

Plan activities for children on peds unit, appropriate activities for school age children?

Building models, playing video games, reading books.

Oxygen delivery systems

Cannula Face Mask Face Tent *Use only low flow oxygen delivery devices to clients with COPD

Nurse at elementary school plans health promo and primary prevention class. Topics for school age children?

Childhood obesity, substance use disorders, scoliosis screening.

Example of Absolute risk

Complication

24-45%

Concentrations of oxygen in the nasal cannula

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? A) A client who has a history of physical abuse B) A client who has a permanent pacemaker C) A client who has ulcerative colitis D) A client who has asthma

D) A client who has asthma

47. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium Rationale: Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

Nurse collects data for older adult. Changes associated with aging?

Decreased height, nail thickening, decreased bladder capacity.

dehiscence vs evisceration

Dehiscence: separation of an approximate wound Evisceration: dehiscence with protruding internal organs. interventions: PLACE SALINE-SOAKED STERILE TOWEL/DRESSING OVER WOUND AND PROTRUDING ORGAN..... DO NOT TRY TO RE-INSERT ORGAN. place patient in supine position with hips/knees bent. keep patient NPO for surgical intervention

incentive spirometers

Designed to mimic natural sighing or yawning by encouraging the client to take long, slow, deep breaths. 2 types: -Flow-oriented -Volume-oriented

Breathing exercises

Diaphragmatic breathing Pursed-lip breathing

Head-to-toe approach when conducting an assessment

Discipline

Client is unstable and need frequent vital signs BP machine is not working properly and needs Bp done every 15 minutes what should the nurse do

Disconnect machine and measure BP manually every 15 minutes

Delegation to UAP

Do Not Delegate: Assessment Teaching Medication Evaluation Unstable Patients

Nurse admits old adult with loss of 4.5 kg from 6 mos. ago. Question to investigate.

Do you eat alone or with someone. Have you started any new meds in past 6 mos what foods have you eaten in past 24 hrs. Are you on a fixed income

When replacing a client's surgical dressing, the nurse should?

Don clean gloves to remove the old dressing

Following a procedure that will happen next month, a client may require a blood transfusion. The client expresses concern to the nurse that they may acquire infection from it. Which response is appropriate from the nurse? Ask provider to order EPO before surgery You should ask provider about iron supplements prior to surgery Request family member to donate blood Donate autologous blood before surgery

Donate autologous blood before surgery

Nurses neighbor is scheduled for elective surgery. They might lose a moderate amount of blood. Which is appropriate for the nurse to suggest

Donating autologous blood before the surgery

What part of hand for skin temp?

Dorsal surface

5. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?

Edema at the infusion site Rationale: Edema due to fluid entering subcutaneous tissue is an indication of infiltration.

Which should community health RNs plan as part of prevention program fir occupational pulmonary disease

Elimination of the exposure

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

Encourage the client to express his thoughts about death and dying- this is the therapeutic technique of reflecting. Do not ask close-ended questions, put the client's issue on hold, or change the subject in response.

Client is admitted to the hospital with decreased circulation in left leg. What is the most important nursing action

Evaluate the pedal pulses

A older client has been on bedrest for one week. He complains about pain in the elbow. What should the nurse do?

Examine the elbow

Impaired gas exchange

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

A nurse is preparing to insert a nasogastric tube for a client admitted with a bowel obstruction following should the nurse do first?

Explain the procedure to the client

Adverse effects of meds

Extrapyramidal Anticholinergic Orthostatic hypotension Bleeding

When communicating to a client that is healing impaired the nurse should?

Face the client & speak slowly

27. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag two-thirds full with ice. Rationale: The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.

Older client who is confused grabs at nurses. Which should be done by nurse

Firmly tell the client not to grab

3 stages of inflammation

First stage: erythma, warm, edema, pain at site of injury 2nd: WBC kill micro orgs, exudate containing WBC and dead tissue cells accumulate at the site. exudate may be serous (clear), sanguineous (bloody), serosanguineous (combo of clear and bloody), or purulent (contains leukocytes and bact) 3rd: damaged tissue is replaced by scar tissue

2-6 L per minute

Flow rates of oxygen in the nasal cannula

A RN has finished teaching a client with diverticulosis about appropriate dietary choices. Which selection by a client on the following day's menu indicates to the RN that the client understands the teaching

Fresh green beans instead of canned for lunch

Before donning gloves hand hygiene is essential. Most important aspect in hand washing is

Friction

Client is ambulating in the hallway with barefeet. What is the priority nursing action at this time?

Get the client's slippers & have him put them on.

hearing loss and aphasia

HEARING LOSS: -face pt and avoid covering mouth -speak slow and clear, use brief sentence -try lowering vocal pitch -do not shout -use sign language interpreter or write down communication APHASIA: -speak clearly and slowly, using short sentence -make sure only one person speaks at a time -give pt plenty of time to response -tell pts if you don't understand them

When assessing a patient's respiration, it is recommended that the patient

Have the head of the bed elevated 45 to 60 degrees -This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.

A nurse is teaching a group of older adults about suspected changes of aging. Which statement by a group member indicates effective teaching? I should expect my HR to take longer to return to normal after exercise. Urinary incontinence is something I have to live with as I get older. I can expect to have less ear wax as I get older. My stomach will empty more quickly after meals as I grow older.

I should expect my HR to take longer to return to normal after exercise.

Nurse reviews 2 y.o. nutrition guideline to parent. they understand if:

Ill give my son 2 tbls of each food at mealtimes.

A client's provider has ordered sputum specimen be collected for culture and sensitivity. The specimen should be collected?

In the morning, on arising

The mother of a toddler calles to the nurse, "help! My baby is choking on his food." The nurse determines the Heimlich maneuver is necessary based on which finding?

Inability of the toddler to cry and speak

ineffective airway clearance

Inability to clear secretions or obstruction from the respiratory tract to maintain a clear airway

Health Care Reg. agencies?

Joint Commission State boards of nursing FDA

Clients waiting for organ transplant, must meet same qualifications

Justice

RN prepares to admit client who is post op. When transferring client from gurney to bed, the nurse should

Lock the wheels on the bed and stretcher

Hydration

Maintain moisture of the resp mucous membranes Thin secretions are easier to expectorate Maintain by drinking thin liquids (unless contraindicated like renal failure or CHF)

A client who is postoperative following a laparotomy is reporting pain and dry mouth. Morphine sulfate ordered to control the pian. Before administering the morphine what action should be done?

Measure the client's vital signs

Federally funded

Medicare Medicaid

Leukotriene modifiers

Medications that suppress the effects of leukotrienes on the smooth muscle of the respiratory tract

A client returns from surgery with two penrose drains in place. Anticipating frequent dressing change the nurse should use what around the incision area?

Montgomery straps

After reviewing meds, which med should nurse administer?

Morphine 2 mg IV

Nasal cannula

Most common and least expensive form of oxygen therapy -Does not interfere with talking or eating -Permits freedom of movement -low concentrations of oxygen (24 to 45%) -Flow rates 2-6 L per minute -Limitation= inability to deliver high concentrations

Med prescription is too extreme

Non-maleficence

A R handed client is admitted with a fractured R arm & contusions on the L wrist. Which intervention should the nurse use when assisting the client with feeding

Offer small bites of food.

A nurse takes takes an older adult client who has dysphagia following a cerebrovascular accident (CVA) to the dining room for dinner. When assisting the client at mealtime, the nurse should?

Offer the client tart/sour foods

Nurse is called to another room to assist another client to the bedpan. RN asks nurse to give injection. Which injection should 2nd nurse take?

Offer to assist client needing the bedpan.

Findings nurse should expect when assessing thyroid gland

Palpating thyroid in lower half of neck Feeling thyroid ascend as client swallows Symmetric extension of trachea on both sides

atelectasis

Partial or total collapse of lung tissue

35. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include?

People who practice Judaism stay with the body of the deceased until burial. Rationale: In the Jewish faith, a family member often stays with the body until burial occurs.

clapping

Percussion sometimes called ________ is forceful striking of the skin with cupped hands. Should produce a hollow, popping sound

Provider's orders

Prescription for DNR and/or AND

Community BP Screening

Primary

MCO requires hospitalization, who must first approve admission?

Provider

assist in patient's understanding of meds

Provider, Pharmacist, RN

Delegating ambulation, Tell AP

Pt ambulates w/ slippers Pt uses walker Pt had pain meds 30 min ago

client transfer back to unit from PACU following surgery

RN is assigned

Pt is not relieved of pain.

Reassess pt to determine why

Self-feeding using adaptive devices

Refer to OT

pulse pressure

SBP-DBP

Client admitted to hospital with terminal stage cancer. RN enters and PT crying what should RN do

Sit & hold client's hand

Dysphagia, refer to

Speech-Lang pathologist

oxygen

Supplied in two ways by portable systems (cylinders or tanks) and from wall outlets.

bruits

Swishing sounds caused by turbulent flow

Client admitted with abdominal pain pt crying while talking about dead father, high temp, abdomen soft and not tender and menses over due for 2 days. What should get priority?

The client's temperature

Evisceration

The displacement of organs outside of the body. nurse interventions: place soaked sterile towel/dressing over wound and protruding organ do not reinsert organ place pt in supine position, with hips and knees bent keep NPO for surgical intervention

A

The nurse makes the assessment that which pt has the greatest risk for a problem with the transport of O2 from the lungs to the tissues? a pt who has: A. Anemia B. An infection C. A fractured rib D. A tumor of the medulla

RN asks by surgeon to witness consent. In signing the form as a witness the nurse affirms that:

The signature on the preoperative consent form is the client's

Hypocalcemia

Trousseau Sign: involves the hand Chvostek Sign: involves the cheek

Fat soluble vitamins

Vitamins A, D, E, K

Nutrition for 11 yo, parent understands guidelines when?

We reward school achievements with a point instead of pizza and ice cream.

To develop a plan of care

What is your primary goal in performing a comprehensive physical assessment?

Dorsal Pedis

When assessing peripheral vascular status of the lower extremities, you place your fingertips on your patients great toe and those of the tow next to it. Which pulse are you palpating?

Inspection

When performing a complete, head to toe assessment, which physical-assessment technique should you perform

enteral feedings d/t dysphagia

semi-fowler's position

Kyphosis

You are performing a physical examination of the spine for an adult. Which of the following findings is common in an older adult?

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? a. Don clean gloves to remove the old dressing b. Loosen the dressing by pulling the tape away from the wound c. Remove the entire old dressing at once d. Open sterile applies after applying sterile gloves

a. Don clean gloves to remove the old dressing

mamogram

annual after 40

moist cold

cold water, cold pack

oral med administration

contraindications: decreased LOC, lack of gag reflex, dysphagia, vomiting place pt in high fowlers position do not mix meds with large amounts of food do not crush enteric coated or extended release meds for liquid meds, the base of the meniscus (lowest point) should be the level of the ordered dose

correct use of walker

do not use walker to stand up flex elbows 20-30 degrees advance walker approx. 12 inches, advance affected leg, then move the unaffected leg forward

Pt. is to receive daily isoniazid (INH) dosage for TB. Pt. states nausea w/med and refuses to take it. Nurse correctly documents refusal by...

documenting reason w/ date and time in medical record

changes with older age eyes ears mouth voice noise

eyes- decreased vision, yellow lens, issue with glare and darkness ears- hearing loss, thickening of tympanic membrane mouth- decreased sense of taste, gum dz, tooth loss, decreased salivation, pale gums voice- increased vocal pitch nose- smell decreased

Catholics

fasting during lent

flatus looks like?

mainly midline protrusion no flanks

antidote for opioid

naloxone

Mormons

no caffeine or alcohol

decreases in RR

opioid/sedative medications, age

Dehiscence

partial or total separation of wound layers

orthopneic position

position that is better at promoting oxygenation than just a high fowlers position. because the organs dont press on the diaphragm. leaning forward a bit. an adaptation of high fowlers position

avoid combustion

post "no smoking" signs avoid synthetic or wool fabrics (wear cotton instead) keep flammable materials away from oxygen equipment (alcohol, acetone, nail polish) no extension cords make sure electrical devices are in good working order and grounded keep > oxygen 8 ft away from heat sources

how to assess thorax

posterior with pt sitting or standing, anterior with pt sitting standing or lying.

a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?

rapid heart rate

Assign to AP

reapply condom cath for pt who is incontinence

wound appearance

red = healthy wound bed yellow = presence of slough/pus (needs cleaning) black = presence of eschar (needs debridement)

sanguineous drainage

red blood cells, reddish color

Bronchodilators

reduce bronchospasm, opening tight or congested airways and facilitating ventilation by dialating bronchioles. -used for acute attacks, wheezes tightness in airway, coughing -use bronchodilater first then antinflammatory inhaler -Albuterol

what should you palpate last?

tender areas

resonance should be heard why and when?

when percussing due to full and reverberating sound that air is in thorax.

how to inspect jugular veins

when pt is lying 30-45 degrees, assess on the right side for signs of heart failure if distended, JVD is if more than 1 in

when preparing to measure vital signs of a patient, you should recognize which will affect the methods that you will use?

- patient is 60 lbs overweight -patient is reporting a stuffy nose -patient is taking digoxin -patient had a mastectomy 2 years ago

respiratory function can be altered by conditions that affect:

-Patency -Movement of air in and out of the lungs -Diffusion of O2 and CO2 between alveoli and pulmonary capillaries -Transport of O2 and CO2 via the blood to and from the tissue cells

nursing care: Hearing loss

-face the pt and avoid covering your mouth -speak slowly and clearly; use brief sentences -try lowering vocal pitch -do not shout -use sign-language interpreter, or write down communication

Tracheostomy care

-give oral care every 2 hours, tracheostomy care every every 8 hours -suction tracheostomy PRN (not routinely) -apply oxygen loosely if patient's spo2 decreases during procedure -use split gauze dressing under tracheostomy plate ( do not cut gauze) -replace trach ties as needed. secure new ties before removing soiled ones home care: cleanse w/ NS using medical asepsis, cover tract when outside

Components of pain assessment

-location of pain -quality (how it feels: burning) -intensity (pain scale from 0-10) -timing (onset, duration, frequency) -setting ( how it affects patient's ADLs) -associated symptoms (nausea, fatigue) -aggravating/ relieving factors (what makes it better or worse)

moving pt from bed to gurney (or vice versa)

-lower HOB -have pt tuck their chin to their chest -tell pt to cross arms over his/her chest -position destination bed/gurney slightly lower

IV care

-maintain IV patency by flushing w/ NS very 8-12 hours when pt isn't receiving continuous IV infusion -change IV sites according to facility policy (every 72 hrs) -replace IV tubing according to policy (every 24-48 hrs) wipe all ports w/ alcohol or antiseptic before connecting lines or a syringe

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? a. Use the pain scale to determine the client's pain level b. Discuss the adverse effects of pain medication with the client c. Obtain the client's vital signs d. Check the client's allergies

. Use the pain scale to determine the client's pain level

Which oxygen therapy must the nurse observe frequently for oxygen toxicity?

100% oxygen via a partial rebreather mask

key conversions

1mg=1,000mcg 1g=1,000mg 1kg=1,000g 1oz=30ml 1 tsp=5ml 1 tbsp=15 ml 1tbsp = 3tsp 1kg=2.2 lb 1gr = 60mg

Apply restraints so __ fingers can fit between restraint and patient. use quick release knot

2

how long should chair sitting be limited to?

2 hrs

correct use of cane

2 points of support on ground at all times position cane on stronger side of body body weight both legs cane 6-10 in front, weak leg forward, then stronger leg past the cane

pts should preform monthly breast exams when? when should post menopausal women do it?

2-3 days after period , postmenopausal is same day each month

Postural Drainage

2-4 hours after meals to reduce the patient's risk of vomiting

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur r/t aortic valve stenosis. At which of the following anatomical areas should the nurse use stethoscope to auscultate aortic valve? 5th IC space just medial to MCL 2nd IC space to L of sternum 5th IC space to L of sternum 2nd IC space to R of sternum

2nd IC space to R of sternum

if the serum albumin level is below what, it will impair healing?

3.5

potassium

3.5-5.0 mEq/L

The nurse should use a _____-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.

35

fill enteral feeding bags with only ___ hours worth of formula to prevent bact. contamination

4

venturi mask

4-12L/min, most precise oxygen delivery, doesnt need to be humidified, best for pts with chronic lung disease.

High Fowler's Position

60-90 degrees; good for severe dyspnea and during meals to prevent aspiration

insert tip for enema ___ cm raise bag ___ cm above anus

7.5-10cm (3-4 in) 30-45cm (12-18 in) above anus if patient is cramping, slow flow by lowering bag

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips

Calcium

9-10.5

CALCIUM levels and function in body

9-10.5 mg/dL bone/teeth formation, nerve and muscle function, clotting

Hypocalcemia

<9 mg/dL causes: diarrhea, vitamin D deficiency, hypoparathyroidism symptoms: POSITIVE CHVOSTEK'S AND TROUSSEAU'S SIGNS, muscle spasms, numbness/tingling in lips/fingers, GI upset

Hypermagnesemia

> 2.1 mEq/L causes: kidney dz, laxatives containing Mg. symptoms: hypotension, muscle weakness, lethargy, respiratory and cardiac arrest

Hypercalcemia

>10.5 mg/dL causes: hyperparathyroidism, long-term steroid use, bone cancer symptoms: constipation, decreased deep tendon reflexes, kidney stones, lethargy

Hypernatremia

>145 mEq/L causes: water deprivation, excess sodium intake, kidney failure, Cushing's syndrome symptoms: tachycardia, muscle twitching/weakness, GI upset, edema

sleep apnea

>5 incidents of breathing cessation in an hour of sleep, each one lasting >10 seconds. use of CPAP

ABCDE Principle

A (airway): ensure pt airway. Stabilize cervical spine if neck/head trauma is suspected B (breathing): assess for respirations C (circulation): check heart rate, blood pressure, and capillary refill D (disability): assess the patient's level of consciousness E (exposure): assess the patient's body for trauma, exposure to heat/cold

A nurse is admitting a client who is having in exasperation of heart failure. While planning this patient's care, when should the nurse initiate discharge planning? A) during admission process B) as soon as the clients condition stable C) during the initial team conference D) after consulting with the clients family

A) during admission process

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A) pad the client's wrist before applying the restraints B) evaluate the client's circulation once per shift after application C) remove the restraints every 4 hours to evaluate the client's status D) secure the restraint ties to the client's bed side rails

A) pad the client's wrist before applying the restraints

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? A. RR is 22/min with even, unlabored respirations B. The clients partner states "he said he hurts after walking about 10 min" C. Pain rating is 3 on a scale of 0-10 D. Skin is pink, warm, and dry E. The assistive personnel reports the client walked with a limp

A- RR is 22/min with even, unlabored respirations D- skin is pink, warm, and dry E, the assistive personnel reports the client walked with a limp

A nurse is caring for a client who has a new prescription for anti hypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on the client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence

A- knowledge

A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen. B. Increase the rate of IV fluids. C. Administer pain medication. D. Initiate cardiac monitoring.

A. Apply supplemental oxygen. Rationale: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A. Auscultate lung sounds B. Measure urine output C. Monitor blood pressure readings C. Monitor serum electrolyte levels

A. Auscultate lung sounds

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A. Erythema on pressure points B. Lower-extremity pulse strength 2+ C. Fluid intake of 3,000 mL of fluid per day D. A bowel movement every other day

A. Erythema on pressure points

A nurse if performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears a bruits. This sound indicates which of the following? A. Narrowed arterial lumen B. Distended jugular veins C. Impaired ventricular contraction D. Asynchronous closure of the aortic and pulmonic valves

A. Narrowed arterial lumen

5) A nurse is caring for a client with diabetes who is to receive hemodialysis. The client says to the nurse, "I don't even know why I'm doing this. There is no cure." Which of the following is an appropriate nursing response?

A: "It sounds as though you have given up."

Anticipatory grief vs complicated grief

A: grieve before an actual loss (family member with terminal illness) C: grief prolonged, severe, interferes with normal function months after loss. No acceptance after 6 months

Pregnancy Categories

ABCDX category A is the safest, X is most dangerous assume all meds are NOT safe during pregnancy

A nurse notices is in a public building and hears" help I am having a heart attack. The nurse arrives and finds an unconscious adult lying on the floor. Another bystander has brought an AED/ The first action needed to be done before ems arrives is?

Administration of cardiac compressions

agonist vs antagonist

Agonist- activates receptor in body (morphine) Antagonist- medication that blocks a receptor in the body (naloxone is an opioid antagonist that blocks opioid receptors, reversing the effects of opioid meds)

A nurse is assisting a client with a meal. The client starts to grab her neck with both hands and looks distressed. The correct response to this?

Ask the client if she is choking

Nurse on a med-surg unit is admitting a client. Which of the following does the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress

Assessment

4. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

Assessment Rationale: The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.

When admitting a client, the nurse records which info in the client's records first

Assessment of the client

A nurse is planning weight-loss strategies for a group of obese clients. Which of the following actions by the nurse will improve the clients' commitment to long-term weight loss? Attempt to increase clients' self-motivation Keep detailed records of each client's progress Test client learning after each teaching session Avoid discussing areas that might cause client anxiety

Attempt to increase clients' self-motivation

Decides not to have surgery

Autonomy

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. "They allow the court to overrule an adult client's refusal of medical treatment." B. "They indicate the form of treatment the client is willing to accept in the event of serious illness." C. "They permit a client to withhold medical information from health care personnel." D. "They allow health care personnel in the emergency department to stabilize a client's condition."

B. "They indicate the form of treatment the client is willing to accept in the event of serious illness."

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? (Select all that apply.) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity

B. Pupil clarity D. Visual fields E. Visual acuity

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses his treatment options and leave the clients room. When the nurse asked if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? A) I will return shortly after I document this in your record B) most men live a long time with prostate cancer C) I am available to talk if you should change your mind D) I will make a referral to a cancer support group for you

C) I am available to talk if you should change your mind

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen. B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen. C. "I'll check the wires and cables on my TV to make sure they are in good working order. D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over.

C. "I'll check the wires and cables on my TV to make sure they are in good working order. Oxygen is a highly flammable gas. The visitors should smoke outside the house.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "Beginning at age 60, you should have a colonoscopy." C. "You should have a fecal occult blood test every year." D. "The recommendation is to have a sigmoidoscopy every 10 years."

C. "You should have a fecal occult blood test every year."

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C. Calf swelling

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect? A. Decreased fremitus B. SaO2 95% on room air C. Temperature 38.8° C (101.8° F) D. Bradypnea

C. Temperature 38.8° C (101.8° F) Rationale: An elevated temperature is an expected finding for a client who has bacterial pneumonia.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? A. The medication B. The route C. The dose D. The frequency

C. The dose

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? A. Drink a cup of hot cocoa before bedtime B. Exercise 1 hr before going to bed C. Use progressive relaxation techniques at bedtime D. Reflect on the day's activities before going to bed

C. Use progressive relaxation techniques at bedtime

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? a. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing

C. Weigh the client on arising

upper airway obstruction

Can occur when a foreign object such as food is present, when the tongue falls back into the oropharynx when a person is unconscious, or when secretions collect in the passageways. -Respirations will sounds gurgly or bubbly as air attempts to pass through the secretions

Suspected Pertussis

Care Plan: wear a mask w/in 3 ft place mask on pt if transfer wear gown if secretions

A postop client has an indwelling catheter with a bag. The bag has been empty for 2 hours. What is the action the nurse should do?

Check if the tubing is kinked

Hospitalized client needs an x-ray. Transporter comes for client when entering client's room what is priority action

Check the client's ID bracelet

First action nurse should take after discovering that the client's wound (1 day postop following abd surgery) has eviscerated?

Cover the incision with a moist sterile dressing

Performing skin assessment for clients. Which finding requires immediate intervention?

Cyanosis

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? A. Biofeedback B. Aloe C. Feverfew D. Acupuncture

D. Acupuncture

Lab results for fluid volume excess

DECREASED: -Hct -serum osmolarity -urine specific gravity (<1.01) unless SIADH -electrolytes, BUN, creatinine

To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this is that

Drying provides the full antiseptic effect A dry environment offers better protection against the proliferation of pathogens than a moist environment does. The bactericidal alcohol components of these gels further enhance their superiors antiseptic effect.

Nurse determines client has abdominal distension via mid-line protrusion, skin over area is taut, & no involvement of flanks. Cause?

Flatus

Promoting effective breathing

Home care oxygenation: -Teach relaxation techniques -Help pt identify specific factors that affect breathing such as stress, exposure to allergens or air pollution and exposure to cold. take measures to avoid these factors

Nurse talking with older adult nutritional improvement. Recommendation?

Increase calcium prevents osteoporosis, limit sodium for edema, increase fiber prevent constipation.

Activity intolerance

Insufficient physiological or psychological energy to endure or complete required or desired daily activities

A PT is admitted to the hospital after being on bed rest @ home. The PT is incontinent and spouse states she is sorry and embarrassed about the smell. Which response by the nurse is therapeutic?

It must be difficult to care for someone who is confined to bed

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

Lock the wheels on the bed and stretcher: Other choices: Instruct the client to raise his arms above his head [arms should be across chest], elevate the stretcher 2.5 cm above the height of the bed [stretcher should be no more than 1.3 cm above height of bed], and log roll the client [used to prevent injury when moving a client who requires immobilization of the neck, back , or spine. Not indicated for a client following abdominal surgery]

Which factors should nurse recognize as altering how children are affected by med?

Lower BP Higher body water content Increased absorption of topical meds

A nurse inserted an indwelling urinary catheter for a male client. Where should the nurse tape the tubing to prevent pressure on the clients urethra at the penoscrotal junction?

Lower abdomen

Cheyne-stokes

Marked rhythmic waxing and waning of respirations from very deep to very shallow with short periods of apnea commonly caused by chronic diseases, increased ICP, and drug overdose.

a history, physical examination, and review of relevant diagnostic data

Nursing assessment of oxygenation status includes

how to treat altitude-related sickness

O2 go to lower altitude provide steroids or diuretics

A nurse is planning care for a client with a NG-Tube following abd surgery. Which of the following should the nurse include in the plan of care

Provide oral hygiene frequently Measure the amt of drainage from the nasogastric tube every 8 hr shift Secure the nasogastric tube to the client's gown.

CPR has been initiated for a client in the emergency room. The nurse understands that a critical concept related to effective chest compressions is?

Push hard & deep on the chest

Drawing Insulin

R.N. (R and then N) Air into NPH Air into Regular Draw up Regular Draw up NPH

While starting an IV for client nurse notices gloved hands are spotted with blood. Clint has not been diagnosed with any blood borne infection. What should the nurse do after completing the tasks?

Remove gloves carefully and wash hands

RACE and PASS

Rescue, alarm, contain, extinguish Pull pin, aim at base of fire, squeeze handle, sweep from side to side

Objective Data

Resp rate 22/min Skin is pink, warm Urine output 300 ml Dressing is clean, dry

Nurse finds pt is allergic to med and gets it changed

Responsibility

5 rights of delegation

Right supervision/eval Right direction/comm Right circumstances

24. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test Rationale: When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.

Sprain & Strain

Sprain: stretches or incomplete tears of a ligament Strain: tendons or muscles are stretched

A nurse is planning care for a client with abdominal pain. An assessment reveals temperature of 102.6 F, HR 105, soft-non-tender abdomen, menses overdue by 2 days. Which of the following findings should be the priority? Heart rate Soft, non-tender abdomen Temperature Overdue menses

Temperature

Father of 12 yo concerned son is not at puberty. First sign of maturation?

Testes and scrotum enlargement

A nurse is planning to obtain the vital signs of a 2- year old who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain a temperature?

The nurse should use the temporal route' noninvasive and can be used to obtain a temp in a toddler who might have an ear infection and who is having diarrhea [other choices are rectal, tympanic, and oral]

Chest tubes

Treat pts who have: -Pneumothorax (remove air) -Hemothorax (remove blood) -Pleural effusion (remove fluid)

Mother tells nurse 2 yr old has tempur tantrums, Child says "no" during getting dressed. Explain

Trying to gain her independence

low flow

Use only ___ ____ oxygen delivery devices to pts with COPD because decreased oxygen concentrations is main stimuli for respiration (hypoxic drive)

oropharyngeal and nasopharyngeal airways

Used to keep the upper air passages open when they become obstructed by secretions or the tongue. these airways are easy to insert and have a low risk of complications. -vary in size -should be well lubricated

Chest tube systems

Water seal Heimlich chest drain valve

43. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown. Rationale: The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.

When taking a patient's BP why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?

You might not hear a fifth Korotkoff sound -Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic pressure. However, with some patient's, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a) Administer the medication with the needle at a 45 degree angle. b) Administer the medication into the client's nondominant arm. c) Pull the client's skin laterally or downward prior to administration. d) Massage the injection site after administration.

a) Administer the medication with the needle at a 45 degree angle.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when installing the eye drops? a. Drop the eye medication in the outer third of the lower conjunctival sac b. Apply gentle pressure in the outer opening of the eye for 2 min c. Hold the eye dropper 0.5 cm (0.2 in) from the cornea d. Instruct the client to close eyes tightly after administration.

a. Drop the eye medication in the outer third of the lower conjunctival sac

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the. nurse take to decrease the risk of a fall? a. Use a gait belt during ambulation b. Ensure the client is earring socks before ambulating c. Instruct the client to sit on the edge of the bed for 15 encodes before ambulating. d. walk 2 feet behind the clients doing adulation

a. Use a gait belt during ambulation

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the vitamins and minerals should the nurse plan to increase in the client's diet? a. Vitamin C and zinc b. Vitamin D c. Vitamin K and Iron d. Calcium

a. Vitamin C and zinc The client's body needs both vitamin C and zinc to help fight a wound infection. The clients should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing

signs of impending death

abnormal breathing, decreased LOC, decreased muscle tone, mottling of skin with cool extremities, decreased pulse and BP, incontinence and decreased urine output, increased secretions in airways **Hearing acuity not decreased during this time

Scoliosis

abnormal lateral curvature of spine (C or S shaped)

taking tympanic temperature

adults-up and back children under 3- down and back excess earwax can affect temp

when is the bladder fully controlled by?

age 4-5

What factors put a pt at risk for falls?

age/developmental status, mobility/balance, knowledge about safety risks, sensory/cognitive status, communication skills, home/work environment, community

crackles or rales

air passing thru fluid in the lungs, fine or course popping (crunching sounds)

PSA/DRE

annual starting age 50

Glucocorticoids

anti-inflammatory drugs, work by decreasing the edema and inflammation in the airways and allowing a better air exchange. -help open up airway -can effect pt immune system and ability to heal if used over long period of time

what types of medications interfere with body's ability to respond to infection?

anti-inflammatory or antineoplastic

passive natural immunity

antibodies are passed from the mom to her baby through the placenta or breast milk

S2 (dub)

aortic and pulmonic valves close

eval client's learning about a diet

ask the pt to explain how to select/prepare meals

pt sitting in chair wants to go to bed

assess pt ability to help w/ transfer

fractures/splinting

assess site for swelling/deformity/skin integrity, assess temp, distal pulses, mobility, apply splint, cover open areas w/sterile cloth, reassess neurovascular after splinting

a nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next?

assess the client for orthostatic hypotension

nursing care for orthostatic hypotension

assist with ambulation have pt sit at edge for 1-2 minutes before standing up change positions slowly

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? a) Admitting diagnosis b) Breath sounds c) Body temperature d) Diagnostic test results

b) Breath sounds

A nurse is chasing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering device is the best choice for the nurse to use to decrease skin irritation? a. abdominal binder b. Montgomery straps c. Hypoallergenic tape d. Plastic tape

b. Montgomery straps

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? a. The lower, medial quadrant of the buttock near the coccyx. b. The side hip between the iliac crest and anterior iliac spine. c. The tissue of the posterior upper arm d. The lower, inner thigh 4 finger widths above the patella

b. The side hip between the iliac crest and anterior iliac spine.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applies sterile gloves to open catheter package b. Wipes the labia minor in an anteroposterior direction. c. Spreads the labia with the dominant hand. D. Uses one cotton ball to wipe the right and left major.

b. Wipes the labia minor in an anteroposterior direction.

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? a. change the colostomy before breakfast b. cleanse the skin around the stoma with warm water c. Change the pouch everyday d. place an aspirin in the ostomy pouch to decrease the odor

b. cleanse the skin around the stoma with warm water

delegation to CNA

bathing, dressing, ambulating, toileting, feeding pt without swallowing precautions, positioning, vital signs, bed making, specimen collection, I + O

When teaching the client the four-point gait, the nurse explains that the client should

be able to bear weight on both legs

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

bladder scan shows 525 mL of urine

first aid

bleeding: apply direct pressure to wound, do not remove impaired object (stabilize instead) fractures: apply splint. Assess for neuromuscular status below injury sprains: use RICE (rest, ice, compression, elevation) frostbite: warm affected area in 98.6-108 degrees F water. administer tetanus vaccine. burns: remove agent causing burn, elevate extremities, administer fluids and tetanus vaccine

serous drainage

blood serum=watery clear, or slightly yellow

fatty tissue lacks

blood supply, slows healing time with obese people

what are bruits?

blowing or swishing sound that means that the peripheral blood flow is obstructed can be heard with the bell of the stethoscope

cyanosis

bluish discoloration of the skin, nail beds, and mucous membranes due to reduced hemoglobin-oxygen saturation)

inflammation

body local response to injury/infection first stage: erythema, warmth, edema, pain at site of injury second stage: WBCs kill microorganisms exudate containing WBCs and dead tissue cells accumulate at the site. Exudate may be; Serous (clear), sanguineous (bloody), serosanguineous (clear and bloody), and purulent (leukocytes and bacteria) third stage: damaged tissue is replaced by scar tissue

specific adaptive immunity

body produces antibodies in response to a specific antigen through action of B and T lymphocytes. Requires more time, but the immune response against that antigen in the future is more efficient.

active natural immunity

body produces antibodies in response to exposure to live pathogen

abdominal assessment

bowel sounds expected: high pitched clicking or gurgling unexpected: loud growling sounds, no bowel sounds after listening for 5 minutes percussion: tymphany sound is expected, dullness over liver (RUQ) expected liver size: 6-12 cm palpate tender areas LAST

newborn nutrition

breast milk and formula for first year solid foods are introduced around 4-6 months no cows milk or honey till 1 yr

newborn nutrition

breastmilk or formula for first year. solid foods introduced at 4-6 mo. no cow's milk or honey until 1 year old

a nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide?

breath sounds

unknown chemical burn pt

brush chem of skin & clothing

A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's intake and output as 120 mL of fluid? a) 2 cups of soup b) 1 quart of water c) 8 oz of ice chips d) 6 oz of tea

c) 8 oz of ice chips

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a) Rock the client up to a standing position. b) Pivot on the foot that is the farthest from the chair c) Assess the client for orthostatic hypotension d) Apply a gait belt to the client

c) Assess the client for orthostatic hypotension

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? a. Auscultate for bowel sounds after each feeding. b. Ensure the formula is cold before administering. c. Elevate the client's head of bed 45 degrees before the feeding d. Flush the tubing with 15 mL of water after the enteral feeding.

c. Elevate the client's head of bed 45 degrees before the feeding

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take? a. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube b. Position the client on his right side c. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

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

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? a. Hold the irrigator 1.25 cm (0.5 in) above the eye b. Direct the irrigation solution upward toward the upper eyelid. c. exert pressure on the bony prominences when holding the eyelids open d. direct the irrigation from the outer cants to the inner cants of the eye

c. exert pressure on the bony prominences when holding the eyelids open

BMI (body mass index)

calculating BMI: BMI = weight (kg)/ height (m) 2 BMI ranges: underweight: under 18.5 healthy: 18.5-24.9 overweight: 25-29.9 obese: 30 +

Client is 2 days postop and RN notes drainage from infected wound on the soiled bed sheet. The nursing action is:

carefully place the soiled sheet in a moisture-resistant plastic laundry bag

Screenings and assessments

colorectal: starting at age 50. fecal occult blood test annually, sigmoidoscopy every 5 years, colonoscopy every 10 years Pap smear: every 3 years starting at age 21 mammogram: annually starting at age 40 testicular exam: at routine health checks starting at age 20 PSA/DRE: annually starting at age 50

pt w/ history of fall

complete fall-risk assess

hypoxia

condition of insufficient oxygen anywhere in the body results, potentially causing cellular injury or death. -Can be related to any part of respiration

decrease inflammation

corticosteriods do what in the airways?

Reviews meds using database

critical thinking: knowledge

secondary lesions

crust: slightly elevated, dried blood/ exudate/ pus (scab) erosion: loss of epidermis, moist (ruptured vesicle) scale: flaky skin (dandruff, eczema) fissure: linear break in skin surface ( result of too dry or too moist skin) ulcer: damage to epidermis and dermis; scarring (pressure injury)

A nurse is planning to collet a stool specimens for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? a. Instruct the client to defecate into the toilet bowl. b. transfer the specimen to a sterile container. c. Refrigerate the collected specimen d. Place the stool specimen collection container in a biohazard bag

d. Place the stool specimen collection container in a biohazard bag

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? a. The wound edges are well-approximated b. The wound is closes at a later date c. a skin graft is placed over the wound bed d. granulation tissue fills the wound during healing

d. granulation tissue fills the wound during healing

Documentation in pt record

date & time in all entries objective data, no opinions

anemia

decreased RBCs and decreased hemoglobin (the oxygen carrying)

late symptoms of hypoxemia

decreased lOC (stupor) bradycardia Dysrhythmias Bradypnea decreased BP cyanosis

musculoskeletal changes with age:

decreased muscle mass decreased bone mass, osteoporosis joint degration decreased ROM

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

distended neck veins

nonmaleficence

do no harm

Correct use of crutches

do not adjust crutch settings after fitting should be 3 finger widths between axilla and top of crutch support body weight on hand grips elbows flexed at 30 degrees walking (non weight bearing): start in tripod position. advance both crutches and the injured leg, then move unaffected leg forward (beyond crutches) sitting or rising from bed/chair: position crutches on unaffected side going up stairs: hold on to a rail with one hand, crutches with other. step up with unaffected leg, bring injured leg and crutches up beside unaffected leg. going down stairs: place crutches and injured leg on step below, then bring unaffected leg down

PCA pump

do not allow others to push button for pt never adjust settings without an order notify provider if pain is not well-controlled

oral meds

do not mix with large amts of food do not crush enteric coated of extended release for liquid meds, the base of the meniscus (lowest point) should be at the level of ordered dose

frostnip

doesn't lead to tissue injury, treated with warming

Vesicle

elevated, serous filled, <1 cm (herpes, varicella)

Bulla

elevated, serous filled, > 1 cm (bister)

Excretion

elimination of meds from body. primarily done through kidneys, but also liver, lungs, intestines affected by kidney dysfunction, can impair excretion of meds, leading to possible toxicity. more common in older adult

Excretion

elimination of meds from the body primarily done by kidneys, but also the liver, lungs, intestines excretion is affected by: kidney dysfunction can impair excretion of meds, leading to possible toxicity more common in elderly

correct use of cane

ensure there are two points of support on ground at all times position on stronger side support body weight on both legs move can forward 6-10 inches, move weaker leg forward, then move stronger leg past cane

a nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene?

erythema on pressure points

disciplining toddlers

establish consistent boundaries

when do flush feeding tubes

flush NG tube with 30 ml water every 4 hours

cognitive learning

focusing on thinking, knowledge, and comprehension

snellen chart -vision

have pt stand 20 ft from chat determines if the pt has myopia (impaired far vision)

wheezes

high pitched, whistling sound, air passing thru narrowed/obstructed airways (louder on expiration)

mass casualty event

highest priority: partial-full thickness burns

Rosenbaum chart

hold 14" away from pt. determines if pt has presbyopia (impaired near vision)

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

i can take echinacea to improve my immune system

Change of shift report

include scan that is scheduled for the day

pts who are immobile should...>?

increase leg exercises, increase fluids, change positions frequently

cardiovascular changes in old age

increased BP blood vessels thicken/harden pulse pressure increases

touch w/out breaching sterile technique

inner wrapping of sterile field irrigation syringe in field 1 glove hand w/ other glove hand

a nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take?

instruct the family to refrain from pushing the button for the client while she is asleep

dehiscence

is a partial or total rupture of a sutured wound, usually with the separation of the underlying skin layers

herpes zoster

isolate pt until vesicles have crusted over avoid pt exposure to individuals who have not had chickenpox or the vaccine admin antiviral medication (acyclovir) and analgesics complications: postherpetic neuralgia, which is pain that continues at least 1 month after rash is gone. prevention: shingles (zoster) vaccine recommended for adults over 60

exhaustion stage

it occurs when stress is prolonged and beyond a person's control result is illness, fatigue, and depression

fidelity

keep your promise

who should use a booster seat in a car?

kids less than 4 ft 9 inches and weigh less than 40 lbs (usually 4-8 yrs)

Primary intention healing

little or no tissue loss, edges approximated as with a surgical incision -heals rapidly, low risk to infection no/minimal scarring

what must staff know about during a fire?

location of exits, alarms, fire extinguishers, oxygen turn off valves. fire doors aren't blocked evacuation plan for unit/facility

accident prevention for toddlers

lock away toxic agents turn pot handles to back of stove safety gates across stairways

During the termination phase of a therapeutic nurse client relationship, the nurse should initiate discussion about the concept of

loss

45 yr w/ no hx of cancer

mammogram each year

Jehovah's Witness

may not accept blood transfusions

islam

no alcohol or pork fasting during Ramadan women must have female providers pray 5 times a day

what is included in the general servey

physical appearance- age, rece, gender, LOC, sign of substance abuse, distress Body structure- height, weight, nutrition, posture, obious abnormalities (amputation) Mobility- gait, ROM, movement Behavior-mood, speech, grooming Vital signs

psychomotor learning has occurred if

pt able to demonstrate approp technique

supine

pt is flat on back

advance directives

pt writes out what he wants

how to use a fire extinguisher: PASS

pull aim squeeze sweep

injury prevention: older adults

remove trip hazards: scatter rugs, loose carpets place electrical cords against wall (behind furniture) install grab bars, use nonskid mat in shower ensure adequate lighting in home, use colored tape on step edges

LPN assignment should not be

replacing tubing on PCA pump

resistance stage

second stage of the stress response; body attempts to return to normal. normalizes hormone levels and VS

severe sore throat, pain swallowing, swollen lymph

stage of inf: convaslescence

Bruits

swishing sound associated with obstructed blood flow (narrowed arteries)

21 guy, hasn't seen doc since high school

testicular exam

Fecal occult blood test

tests for blood in stool collect 3 samples from 3 different BMs do not allow contamination with water/urine for point of care testing, blue color indicates positive result (blood present)

Ishihara test

tests for color vision

safety for infant

took away crib gym from baby

veracity

truthfulness

patient transfer

use SBAR situation, background, assessment, recommendations

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

"The client reports severe pain." A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity. Asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, he does have a readiness to learn the activity. Asking about the frequency of the activity indicates a readiness to learn. The client's statement (the client tells the nurse that this exercise will probably be painful after surgery) indicates to the nurse that the client has a readiness to learn because he is able to think about the possible effects of the exercise following the surgery.

7) A client is scheduled for a lumbar puncture to rule out bacterial meningitis and tells the nurse that he is fearful of becoming paralyzed from the needle being place in the spinal column. Which of the following is a therapeutic response by the nurse?

"The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends."

A nurse is teaching an assistive personnel about proper hand hygiene. Which statement from AP indicates understanding? "There are times I should use soap and water instead of alcohol-based sanitizer" "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down."

"There are times I should use soap and water instead of alcohol-based sanitizer"

A nurse is teaching an assistive personnel [AP] about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." While alchol-based rubs are as effective as soap and water in providing proper hand hygiene, the CDC and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. Friction should be applied for 15-20 seconds, and drying should be performed from the hands down to the elbows. Hand hygiene should be performed with warm water.

A client who has been diagnosed with cancer tells the nurse, "I would rather be dead than go through the treatment for cancer. "Which of the following is an appropriate response by the nurse?

"What is it about the cancer treatment that concerns you?"

2) After teaching a client how to perform personal colostomy care prior to discharge. The client says to the nurse, "I don't think that I am going to be able to take care of this myself." Which of the following is an appropriate response by the nurse?

"What part of the colostomy care are you having trouble with?"

An adult child has come to take a parent home from the hospital following a colon resection. The adult child tells the nurse, " I don't know how I am going to take care of my parent now." Which of the following is an appropriate response?

"What part of your parent's care are you concerned about?"

An older adult client is admitted to the hospital for surgery for a fractured hip. The client says to the nurse, "I guess I've lived long enough, and it's my time." Which is the therapeutic response by the nurse?

"You feel that your life is ending?"

1) A nurse caring for an adolescent client in the community health center who has a positive (HCG) test. She tells the nurse, "I don't think I can tell my parents that I am pregnant." Which of the following is an appropriate response?

"You seem frightened to tell your parents."

heart assessment

"all physicals eagerly take money" aortic, pulmonic, erb's point, tricuspid, mitral

PVD sequence

(postural drainage) 1. positioning 2. percussion 3. vibration 4. removal of excretions change position and repeat process

Steps in Insulin Administration

**remember CLEAR before CLOUDY -inject air into longer-acting insulin (NPH) -inject air into short-acting insulin (regular insulin). Do not remove needle. -draw up short-acting (clear) -draw up long-acting (cloudy)

Topics to Review:

- 6 Rights - NG tube -Pre-Admin Assessment -Inhaler Spacer -Dosage calculator

which of the following patients is exhibiting drug tolerance?

- A patient requires an increased dose of a medication to achieve continued therapeutic benefit. * As tolerance develops to a medication, a patient requires higher and higher doses of that medication to achieve the desired effect.

Which of the following represents the correct administration of the prescribed medication?

- Amoxicillin 1 g PO prescribed; two 500-mg tablets given * To determine the correct dosage, start with the amount prescribed: 1 g (gram). To determine how many tablets to give, divide the dose ordered by the dose on hand and multiply the result by the amount on hand. So, 1 g (dose ordered, and also equivalent to 1,000 mg) divided by 500 mg (dose on hand) = 2, then 2 X 1 (amount on hand) = 2 tablets. So this is the correct amount to give.

You are reading the physician's orders and note date and time of the prescriptions, as well as the physician's signature. Which of the following prescriptions is complete?

- Digoxin (Lanoxin) 1.25 mg PO daily * This order is complete with medication dose, the route, and the frequency of administration.

Which of the following is your highest priority action for ensuring overall safety during medication administration?

- Identify the patient by two acceptable methods. * One of the six rights of medication administration is to identify that you are giving the medication to the correct patient. It is required that you check the medication administration record against the patient's identification bracelet, and use a second method of patient identification, such as asking the patient his birth date.

With which route of drug administration are there no barriers to absorption?

- Intravenous * The definition of absorption is the movement of a drug from its site of administration into the blood. With intravenous administration, the drug is injected directly into a vein. Thus any possible barriers to absorption are bypassed, and the drug is completely and instantaneously absorbed.

Which of the following is the most appropriate documentation of a patient's response to a pain medication?

- The patient reports pain decreased to 3/10, 30 minutes after medication administration. * Using a standardized instrument is the most appropriate method of documenting a response to pain medicatio

Applying face mask

-Assess for appropriate size -Apply from the nose downward -Fit mask to contours of client's face -Secure the elastic band around the head so mask is comfortable but snug -Pad the band behind the ears and over bony prominences to prevent irritation

Face tent

-Can replace mask when poorly tolerated -Varying concentrations 30-50% -4-8 Liters per minute Frequent assessment required: (Dampness or chaffing, Dry and treat as needed, Facial skin must be kept dry)

Planning for home care

-Consider pts learning and assistance needs -Family knowledge -Abilities of self-care -Financial resources -Evaluation for home health care

Percussion

-Cover area with towel or gown -Ask pt to breathe slowly and deeply to promote relaxation -Fingers and thumb are held together to form cup -Use over congested lung areas to dislodge secretions from bronchial walls -Alternatively flex and extend wrists rapidly to slap the chest -percuss 1-2 min over affected lung -cystic fibrosis

Using an interpreter

-DO NOT use patient's family or friends -use certified medical interpreter -explain purpose of meeting to interpreter prior to approaching the patient -direct questions at family, not interpreter -use layman's terms (NOT medical jargon) -DO NOT supplement words with gestures or nonverbal reinforcement

Simple face mask

-Delivers oxygen concentrations from 40-60% -5-8 Liters per minute

partial rebreather mask

-Delivers oxygen concentrations from 60-90% -6-10 Liters per minute -Client breathes 1st third of already exhaled air, increasing Fi02 (fraction of inspired oxygen) -Must not totally deflate during inspiration to avoid carbon dioxide build-up -If bag deflates nurse increases liter flow of oxygen

Nasophyrangeal and nasotracheal suctioning

-Fowler's or high Fowler's -Lubricate distal 6-8 cm of catheter with water soluble lubricant -Insert catheter during inhalation. insert distance from tip of nose to base of earlobe -APPLY SUCTION INTERMITTENTLY WHILE WITHDRAWING THE CATHETER AND ROTATING IT OR 10-15 SECONDS -Perform up to 2 passes, waiting 1 minute between passes

Endotracheal suctioning

-Fowler's or high Fowler's -catheter diameter should be <= half of diameter of the endotracheal tube -Hyperoxygenate the patient with 100% O2 prior to and in between suctioning -USE SUCTION PRESSURE OF 120-150 mmHg -advance catheter until you reach resistance, pull back 1 cm (above carina) prior to suctioning -APPLY SUCTION INTERMITTENTLY WHILE WITHDRAWING THE CATHETER AND ROTATING IT FOR 10-15 SECONDS -do not reuse suction catheter

Assessment of chest tube

-Integrity of system -VS, O2 Sat, Respiratory and CV system -Dressing -Infection -SubQ emphysema (around site of chest tube) -Pain -Drainage -Encourage deep-breathing & coughing -Reposition -ROM -Device below level of chest -Avoid aggressive tube manipulation -Avoid clamping unless necessary

outcomes/goals for pt with oxygenation problems

-Maintain a patent airway -Improve comfort and ease of breathing -Maintain or improve pulmonary ventilation and oxygenation -Improve ability to partipate in physical activities -Prevent risk associated with oxygenation problem

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. -Place a name tag on the body -Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -Wash the client's body -Ask the client's family members if they would like to view the body

-Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -Wash the client's body -Ask the client's family members if they would like to view the body -Place a name tag on the body

44. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. Rationale: -Provide oral hygiene frequently is correct. Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. -Measure the drainage from the NG tube every shift is correct. Measuring the drainage at least every shift helps the provider to calculate fluid loss and prescribe appropriate replacement therapy. -Secure the NG tube to the client's gown is correct. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.

promoting healthy breathing

-Sit straight and erect for full lung expansion (orthopneic position is helpful) -Exercise regularly -Breath through nose -No smoking -Eliminate or reduce pesticides and chemicals -Avoid second hand smoke -Make sure adequate ventilation -Support a pollution-free environment

Venturi mask

-Varying concentrations: 24; 40; or 50% -4-10 Liters per minute -Wide-bore tubing and *color coded* jet adapters corresponding to oxygen concentration amount and liter flow -percise oxygen concentration

best practices for taking a pmts blood glucose

-clean finger with warm water and soap or antiseptic (no alcohol) -use warm, moist towel to increase circulation -place hand in dependent position -pierce outer edge of fingertip, holding lancet perpendicular to skin. be sure to rotate sites -wipe away first drop of blood -hold test strip next to drop of blood on fingers (do not smear blood on strip)

Foley Catheter Care

-clean insertion site with soap and water three times a day and after bowel movements -keep collection bag below level of bladder -make sure tubing is not kinked (and no dependent loops)

FOB test (tests for blood in stool)

-collect 3 samples from 3 different bowel movements -DO NOT ALLOW contamination with water or urine -for point-of-care testing, blue color indicates positive result (blood is present)

informed consent: Provider responsibility

-communicate purpose of procedure, and complete description of procedure in the patient's primary language (use medical interpreter if needed) -explain risks vs. benefits -describe other options to treat the condition

practices to prevent the spread of microorganisms

-cover mouth/nose when sneezing or coughing -use tissues, dispose of them properly -stand at least 3 ft away from those coughing (or have Tham wear a mask) -keep nails short, no artificial nails or gel polish -frequent hand hygiene; remove jewelry from hands/wrists -DO NOT shake linens -clean least soiled areas first in patients room -do not place items on the floor

24 hr urine collection

-discard first void, collect all urine for 24 hrs -do not allow contamination of stool -keep urine on ice

informed consent: RN responsibility

-ensure the provider gave the pt the above information -ensure pt is competent to give informed consent (adult, emancipated minor, not impaired) -have patient sign consent document -notify provider if pt has more questions or doesn't understand any information provided.

Preventing constipation

-increase fluid intake (2-3 L/day) -increase fiber intake (25-30g/day) increase activity (stimulates peristalsis) DO NOT USE laxatives long-term (can cause chronic constipation)

carbon monoxide

-oderless, tasteless -carbon monoxide binds to hemoglobin, reducing O2 supplied to the body -use carbon monoxide detectors -maintain proper ventilation when using fuel-burning items (wood stoves, gas fireplaces) -know symptoms of carbon monoxide poisoning: n/v, headache, and loss of consciousness

Tracheostomy care

-oral care every 2 hours, trach care every 8 hours -suction trach PRN (not routinely) -Apply oxygen loosely if patient's SpO2 decreases during procedure -use surgical asepsis to remove and clean inner cannula -use split gauze dressing under trach plate (DO NOT CUT GAUZE) -replace trach ties as needed. secure new ties before removing soiled ones. -Home care: cleanse w/ NS using medical asepsis, cover trach when outside

injury prevention: food poisoning

-perform frequent hand hygiene -immunocompromised individuals (higher risk) should only consume pasteurized dairy products refrigerate perishable products within 2 hours (or within 1 hr when temperature is 90 degrees or more) -prevent cross-contamination during food prep (handle raw and fresh food separately) -cook foods to recommended temps

Diaphragmatic (or abdominal) breathing

-permits deep full breaths without a lot of effort. -Usually done semi sitting in bed or in a chair. -Flex knees and relax abdomen muscles breathe deeply thru nose and keep mouth close -Concentrate on feeling abdomen rise as far as possible without arching back and stay relaxed and take deep relaxed breaths

nursing care for a patient with dysphagia

-place patient in Fowler's or high-fowlers position -give one med at a time -lightly stroke chin/throat to promote swallowing -thicken thin liquids -check for food pockets in mouth before feeding -encourage pt to tuck their chin when swallowing -monitor pt during meals, have suction set up -avoid straws

nasopharyngeal and nasotracheal suctioning

-place pt in Fowler's or high-fowlers -lube distal 6-8 cm of catheter with water-soluble lubricant -insert catheter during inhalation. insert distance from tip of nose to base of earlobe -apply suction intermittently while withdrawing the catheter, and rotating it for 10-15 seconds -perform up to 2 passes, waiting 1 minute in between

setting up a sterile field

-position package with top flap facing away from you -open top flap away from you -open right side flap with right hang, then do the left with your left hand -open last flap towards you

changing ostomy pouch

-remove pouch, inspect stoma (should be red/pink, moist) and skin (should be intact) -clean skin with soap and water, dry thoroughly. Do not use moisturizers -cut opening in skin barrier <= 1/8 inch larger than stoma (no bigger) -apply skin barrier and pouch, using barrier paste as needed for creases

Denture Care

-remove upper dentures by pulling down and out -remove lower dentures by pulling up and out -brush w/ toothbrush and denture cleaner - store in cup (labeled) with water to keep moist

nursing care: aphasia

-speak clearly and slowly, using short sentences -make sure only one person speaks at a time -give patient plenty of time to respond -tell patients if you do not understand them

Mandatory reporting for RN

-suspicion of abuse (child, elderly, domestic violence) -communicable diseases to local/state health department (mandated by state)

preventing pressure injuries and skin damage

-turn patient Q2 -limit chair/wheelchair sitting to one hour, advise pt to shift weight every 15 minutes, use pressure-relieving device -ensure proper hydration and nutrition (especially protein) -keep HOB <=30 degrees. rise heels off of bed. -lift (vs pull) patients up in bed -DO NOT massage bony prominences DO NOT use powder or cornstarch

IM medication administration

-use 1-1.5 inch, 18-27 gauge -use vastus lateralis for infants <= 1 year old -ventrogluteal site is best for volumes over 2 ml -deltoid site is limited to volume up to 1 ml -inject at 90 degree angle. use z-track method

subcutaneous medication administration

-use 3/8-5/8 inch, 25-27 gauge needle. or use insulin syringe (28-31 gauge) if administering insulin -inject volumes up to 1.5 main fatty areas (abdomen, lateral upper arms) at a 45-90 degree angle. Use 90 degree angle for obese patients

Non-opioid analgesics

-use for mild to moderate pain -acetaminophen Intake should not exceed 4 g/day. -monitor for salicylism w/ aspirin (tinnitus, vertigo) -administer w/ food to prevent GI upset -long-term NSAID use carries risk of bleeding

NG/G tube medication administration

-verify tube placement -administer each med separately -dissolve tablets in 15-30 ml sterile water -flush tube before and after each medication with 15-30 ml water (including after all meds are given)

Administering an enema

-warm enema solution -position pt on left side with right leg flexed (sims position) -lubricate tip/nozzle -insert tip 7.5-10 cm ( 3-4 inches) -raise bag 30-40 cm (12-18 inches) above anus -if pt has cramping, slow flow by lowering the bag

a nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has a myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family?

1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure

1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle

a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? select all that apply

1)place the client in a room with negative-pressure airflow 2) wear gloves when assisting the client with oral care 3) use antimicrobial sanitizer for hand hygiene

nasal cannula

1-6L/min also can deliver 10-15L/min

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?

1. Ask the client if he can bear weight 2. Position the chair on the left side of the bed 3. Have the client sit and dangle his feet at the bedside 4. Use the stand-and-pivot technique to move the client to the chair

50. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

"All of this equipment can be frightening." Rationale: This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.

How to use an incentive spirometer

1. Hold in upright position 2. Exhale normally 3. Seal lips tightly around mouthpiece 4. Take in slow deep breaths to elevate the balls or cylinder for 2-6 seconds (start low) 5. Avoid brisk low-volume breaths 6. Remove mouth piece and exhale normally 7. Cough after the incentive effort 8. Relax and take several breaths before using again 9. Repeat the procedure several times and four to five times per hour 10. Clean mouth piece and shake it dry.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

1. Inject 10 units of air into the bottle of NPH insulin. CLOUDY. 2. Inject 5 units of air into the bottle of regular insulin. CLEAR. 3. Withdraw the correct dose of regular insulin from the bottle. CLEAR. 4. Withdraw the correct dose of NPH insulin from the bottle. CLOUDY. Cloudy insulin (NPH, Humulin N, Novolin N) should NOT enter clear insulin (regular, Humulin R, Novolin R) Inject air into cloudy, Inject air into clear, Draw up clear, Draw up cloudy

14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs." Rationale: The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs.

A nursing assistant is caring for a client who is unconscious. While bathing the client, the nursing assistant describes the weather and chats about current events. The client's wife says to the nurse, "Why does the nursing assistant talk to my husband? He's unconscious.." The nurse should respond by stating,

"Clients like your husband, who are unconscious, may still be able to hear."

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

"Donate autologous blood before the surgery"- Autologous blood transfusion is the collection and re-infusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safetest form of blood transfusion because exclusive use of a client's own blood eliminates exposure of transfusion-based infection. Wrong responses: "Ask your provider to prescribe epoetin before the surgery": Epotein is a hematopoietic growth factor used for the treatment of anemia. While taking eopoetin prior to surgery can boost the client's hematocrit levels, it is inappropriate if the client already has adequate hematorcit level. Iron isn't needed if the client has sufficient hemoglobin, and requesting a family member to donate blood does not eliminate the risk of acquiring infection.

30. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you." Rationale: The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.

Nurse counsels young adult with several issues, what is priority?

"I don't know who I am yet, or what to do"

Nurse talking to adolescent who has difficulty dealing with issue. Priority problem for assessment and intervention?

"I don't seem to be good at anything. I cant play sports at all"

After administering the preop benzodiazepine, lorazepam as prescribed, the nurse determines that the med was effective when the PT says

"I feel very sleepy"

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

"I keep having nightmares about my upcoming surgery"= nightmares and sleep disturbances are manifestations of anxiety and PTSD. These indicate that the client is at risk for experiencing psychological distress. Clients who have social and emotional support systems tend to experience less psychological distress. Open communication is an important method to improve relationships that might be strained. Seeking counseling is a positive strategy. Clients who have social and emotional support systems tend to experience less psychological distress.

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during. The pulse rate also takes longer to return to normal after exercise. Urinary incontinence is not an expected incidence, older adults have increased buildup of cerumen, and decreased gastric emptying.

Nurse teaches daughter of older adult pt. how to instill eyedrops in pt's R eye. What indicates that the daughter understands?

"I will pull down her lower eyelid and drop the med in."

When approached by a nurse, a client with major depressive disorder says, "Don't bother me. Find someone else to talk with. I don't have anything worth saying. Go find someone you can help." Which of the following is a therapeutic response?

"I would like to sit quietly with you for a while."

RN tells client that Dr and prescribed IV fluids. Client appears upset, but doesn't say anything what should RN say

"Is there something about this procedure that concerns you?

A nurse is caring for a client who had a spontaneous abortion at 9 weeks of gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following is a therapeutic response?

"It is hard to deal with a pregnancy loss. Here is the number of a local support group that you could attend."

10. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed." Rationale: This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.

4) A nurse is caring for an older adult client who dies during the night with his wife at his side. The wife says to the nurse, "I can't believe he's gone." Which of the following is a therapeutic response by the nurse?

"It must be hard to accept that this has happened."

A nurse is caring for a 13 year old is admitted for an emergency appendectomy. While doing the preoperative teaching, the client asks, "Will I have a large scar from the surgery?" Which of the following is an therapeutic response?

"It will be small enough so it wont show when you're wearing a bathing suit."

6) A client with a suspected brain tumor is scheduled for a CAT. When the procedure is explained, the client expresses fear of entering the enclosed space of the scanner. Which of the following responses by the nurse is appropriate?

"Let me review some breathing exercises with you."

8) A nurse is caring for a client with leukemia. The client says to the nurse, "The doctor told me that my condition is too severe to be treated successfully, and I am no longer a candidate for chemotherapy. I guess I don't have long to live." Which of the following responses by the nurse is therapeutic?

"Let's talk about how you are feeling about this information."

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

"Perform hand hygiene"- According to EBP, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurses's hands is a primary source of infection. The nurse should also, after performing hand hygiene, don sterile gloves, stabilize the tracheostomy tube, and open all supplies and solutions.

3) An ED nurse takes a telephone call from a client who reports "I have just taken 100 amitriptyline (Elavil) tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live." Which of the following responses by the nurse is appropriate?

"Please stay on the phone with me so we can talk about your feelings."

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal."- Increased peristalsis occurs after food enters the stomach. Siting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. The nurse should instruct the client to consume a minimum of 1,500mL of fluid to prevent constipation. The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods. The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.

RN is teaching PT with residual hemiplegia so RN instructs client to do which of the following when putting on the shirt?

"Slide your weaker arm through its sleeve first"

48. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you." Rationale: The nurse should ask an open-ended question that encourages the client to elaborate about the problems that he is having.

A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections."- This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.

An adolescent client is just diagnosed with testicular cancer. When the nurse asks the client a question, he angrily spits in the nurse's face. Which response by the nurse would be appropriate?

"That behavior makes me very angry, and I will not tolerate it."

9) When a nurse is making morning rounds, a client says, "I almost died last night." Which of the following is a therapeutic response by the nurse?

"That must have been frightening for you. Tell me more about it."

face mask

5-8 L/min w/pts who have anxiety or clausterphobia this is not a good method

Of the patient who had abdominal surgery in the last 2 days, which patient should you assess first?

70 yo woman who vomited 2x in last 4 hours

pt closest to nursing station, to prevent falls

79 post-op following below-the-knee amputation

a nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump?

8 mL/hr

Bladder of BP cuff should surround ____% of arm circumference

80

sleep apnea

>5 incidents of breathing cessation in hour of sleep one lasting > 10 seconds CPAP used for patients with sleep apnea

Hyperkalemia

>5.0 mEq/L causes: uncontrolled diabetes (DKA), metabolic acidosis, salt substitutes, kidney failure symptoms: DYSRHYTHMIAS, muscle weakness, numbness/tingling, diarrhea, confusion

16. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month-old infant can pull up to a standing position. Rationale: An 8 to 10-month-old infant can pull himself to a standing position.

9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells Rationale: Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.

You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear?

A face shield A face shield protects face, mouth, nose and eyes from potential splashes of blood or other body fluids. Irrigating a wound certainly has the potential for splashing irrigating fluid containing blood, body fluids, and tissues particles onto your face.

A client recovering from an appendectomy for a ruptured appendix has a surgical wound secondary intention. When changing the dressing would should the nurse report to the physician or surgeon?

A halo of erythema on the surrounding skin.

You have assessed a 45 yr old patient's vital signs. Which of the following assessment values requires immediate attention?

A respiratory rate of 30/min An oral temp. of 100 F indicates a fever but this degree of elevation in body temp is rarely a situation that requires immediate attention

the pressure delivered during exhalation is less than the pressure delivered during inhalation

A variation of (CPAP) is bilevel positive airway (BiPap) in which:

RN is caring for a PT who is 2 days postop following abd surgery. The nurses should be concerned about which of the following findings?

A wound dressing with thick, light green drainage

A nurse is planning care for a client who had a stroke, resulting in aphasia and dysphasia. Which of the following tasks should the nurse assigned to an assistive personnel? (Select all that apply) A) Assist the client with a partial bed bath B) measure the client's BP after the nurse administers an antihypertensive medication C) test the client's swallowing ability by providing thickened liquids D) use a communication board to ask what the patient wants for lunch E) irrigate the client's indwelling urinary catheter

A) Assist the client with a partial bed bath B) measure the client's BP after the nurse administers an antihypertensive medication D) use a communication board to ask what the patient wants for lunch

A nurse is caring for a child who has a prescription for a blood transfusion. The parents refuse the treatment due to religious believes. Which of the following action should the nurse take? A) Examine personal values about the issue B) tell the parents that this is a necessary procedure C) inform the parents that the staff does not require their consent D) contact a spiritual support person to explain the importance of the procedure

A) Examine personal values about the issue

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? A) Thread the IV catheter so that the hub rests at the insertion site B) shave excess hair from around the insertion site C) cleanse the site with hydrogen peroxide before the IV catheter insertion D) palmate the site carefully just before inserting the IV catheter

A) Thread the IV catheter so that the hub rests at the insertion site

A nurse has an order to remove the sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following action should the nurse take? A) clean sutures along the incision site B) grasp at the knot of the sutures with forceps C) cut the sutures close to the skin on one side D) pull out the

A) clean sutures along the incision site

A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? A) second intercostal space at the left sternal border B) fourth intercostal space at the right sternal border C) fourth intercostal space at the left sternal border D) second intercostal space at the right sternal border

A) second intercostal space at the left sternal border

A nurse is caring for a group of clients on a major medical surgical unit. Which of the following situations does the nurse demonstrates ethical principle of veracity? A) the client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse response affirmatively B) a client who is a prescription for a nasogastric tube refuses it and the nurse complies with the clients wishes C) a client with a DNR status has a cardiac arrest and the nurse does not perform CPR despite request from the clients family D) a client who was about to undergo a painful procedure receives pain medications 30 minutes before the procedure that the nurse promised she would

A) the client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse response affirmatively

The charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field? A) the nurse opens the sterile field on the wet surface B) the nurse opens the fold away from his body C) the nurse hold sterile objects above the waist D) the outer edge of the sterile field is touching a bottle

A) the nurse opens the sterile field on the wet surface

A nurse is teaching a client who's left leg is in a cast about using crutches. Which of the following statements for the nurse identify as an indication of the client understands teaching? A) when descending stairs I will first shift my weight to my right leg B) I should place my crutches 12 inches in front and to the side of each foot C) as I sit down I will hold one crutch in each and D) I will make sure the shoulder rests are snug against my armpits

A) when descending stairs I will first shift my weight to my right leg

pregnancy categories for medication admin

A, B, C, D, X A-safest X-most dangerous ASSUME ALL MEDS ARE NOT SAFE DURING PREGNANCY routine/standard rx, give within 30 min bfore or after scheduled time stat now: within 90 min PRN: rx includes dose, frequency, and what under what conditions it can be administered standing: rx that can be given for specific circumstances on specific units

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A- assessment

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food". The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurses report and prescribes a full liquid diet. The nurse use which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity

A- basic

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A. Do not measure the clients temperature rectally B. Count the clients radial pulse for 30 seconds and multiply it by 2 C. Do not let the client know you are counting her respiration's D. Let the client rest for 5 min before you measure her blood pressure

A- do not measure the clients temp rectally

A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. I will determine the most important client problems that we should address B. I will review that last medical history of the clients record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if his nausea has resolved

A- i will determine the most important client problems that we should address

A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select al that apply) A. Poor wound healing B. Dry hair C. Blood pressure 130/80 D. Weak hand grips E. Impaired coordination

A- poor wound healing B- dry hair D- weak hand grips E- impaired coordination

By the second post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lessens during the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing pain

A- reassess the client to determine the reasons for inadequate pain relief

A nurse is teaching a group of women about risk factors for osteoporosis. Which of the following risk factors should the nurse include? (Select all that apply) A. Inactivity B. Family history C. Obesity D. Hyperlipidemiq E. Cigarette smoking

A-Inactivity B-family history E-cigarette smoking

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "It is difficult to read the instructions because my glasses are at home." C. "I'm wondering why I need to learn this." D. "You will have to talk to my wife about this."

A. "I can concentrate best in the morning."

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statement should the nurse manager plan to include in the teaching? A. "Use the complete name of the medication magnesium sulfate." B. "Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin.: D. "Use the abbreviation SC when indicating an injection."

A. "Use the complete name of the medication magnesium sulfate."

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?"

A. "What could I have done to deserve this illness?

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? A. A client who has epistaxis B. A client who has amyotrophic lateral sclerosis C. A client who has pneumonia D. A client who has emphysema

A. A client who has epistaxis Rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A. A client who is 48 hr postoperative following a total hip arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A. A client who is 48 hr postoperative following a total hip arthroplasty Rationale: The nurse should identify that the client who has undergone a total hip replacement surgery is at greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devises or antiembolic stockings and by administering anticoagulant medications.

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement? A. Airborne B. Neutropenic C. Contact D. Droplet

A. Airborne Rationale: The nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure filtered through a high-efficiency particulate air (HEPA) filter. Members of the healthcare team should not enter the client's room without wearing an N95 respirator mask.

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? A. Allow extra time for the client to respond to questions B. Expect the client to have difficulty understanding the information C. Avoid references to the client's past experiences D. Keep the learning session in private and one-on-one

A. Allow extra time for the client to respond to questions

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? A. Ask another nurse to observe the medication wastage B. Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substances cabinet D. Dispose of the vial with the remaining medication in a sharps container

A. Ask another nurse to observe the medication wastage

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect? A. Blood-tinged sputum B. Decreased tactile fremitus C. Resonance with percussion D. Peripheral edema

A. Blood-tinged sputum Rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries B. Move hazardous objects away from the client C. Notify the provider D. Ask the client to describe how she felt prior to the fall

A. Check the client for injuries

A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hrs. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked b. Palpate the bladder c. Obtain a prescription to irrigation the catheter with 0.9% sodium chloride. d. Encourage the client to drink more fluids.

A. Check to determine if the catheter tubing is kinked

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for cultural and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen upon arising in the morning. B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 ml of sputum before sending it to laboratory

A. Collect the specimen upon arising in the morning

A nurse is caring for an 82 year old client in the emergency department who has an oral body temperature of 101, pulse 114/ min, rr 22/ min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply) A. Obtain culture specimens before initiating antimicrobials B. Restrict the clients oral fluid intakes C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently

A. Obtain culture specimens before initiating antimicrobials C. Encourage the client to rest and limit activity E. Assist the client with oral hygiene frequently

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2 hr increments D. Wear a surgical mask when providing client care E. Use antimicrobial sanitizer for hand hygiene

A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care E. Use antimicrobial sanitizer for hand hygiene

A nurse is instructing a group of nursing students in measuring a clients rr. Which of the following guidelines should the nurse include? A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe on full respiratory cycle before counting the rate D. Count the rate for 30 seconds if it is irregular E. Count and report any sighs the client demonstrates

A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe on full respiratory cycle before counting the rate

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments? A. Presence of gag reflex B. Pain level rating using a 0-10 scale C. Hydration status D. Appearance of the IV insertion site

A. Presence of gag reflex Rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragus of the client's ear B. Pack a small piece of cotton deep into the ear canal C. Move the client's auricle down and back toward her head D. Tilt the client's head back for 5 minutes

A. Press gently on the tragus of the client's ear

Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feed

A. Use an open posture C. Establish and maintain eye contact E. Respond positively when giving feed

A nurse is assisting the provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (Select all that apply.) A. Wear goggles and mask during the procedure. B. Cleanse the procedure area with an antiseptic solution. C. Instruct the client to take deep breaths during the procedure. D. Position the client laterally on the affected side before the procedure. E. Apply pressure to the site after the procedure.

A. Wear goggles and mask during the procedure. B. Cleanse the procedure area with an antiseptic solution. E. Apply pressure to the site after the procedure. Rationale: Wear goggles and mask during the procedure is correct. The nurse and provider should wear goggles and a mask to reduce the risk of exposure to pleural fluid. Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk of infection, which is increased due to the invasive nature of the procedure. Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk of bleeding at the procedure site.

A nurse is caring for a patient who is postop and has a paralytic ileum. Which of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention: paralytic ileum is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended. There is no flatus or stool, and there is decreased peristalsis.

____ risk that doesn't involve group comparison

Absolute

A patient has a nosocomial infection. This terminology means that the patient

Acquired the infection while hospitalized A nosocomial infection is one that is acquired in a hospital. Most nosocomical infections are caused by pathogens transmitted from one patient to another by healthcare workers who do not practice good hand-hygiene technique or do not disinfect their hands between patient contacts. Note that the term CDC prevention now uses for infections associated with health care delivery in any setting (hospital, long-term care facilities, ambulatory setting, home care) is healthcare- associated infection.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night- to soothe the client's throat following a tonsillectomy, the nurse should administer pain meds on a routine schedule around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route. The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding. The nurse should offer an ice collar, not a heating pad, to ease the child's pain. Milk products, such as ice cream and pudding, are usually avoided because they coat the mouth and throat, causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy.

Airborne precautions Droplet precautions Contact

Airborne- measles, varicella, TB private room Negative airflow room N95 masks Droplet- influenza, pneumonia, pertussis, mumps, sepsis, rubella, bact meningitis Masks Contact-imetigo, scabies, MRSA, VRE, CDIFF, RSV, wound -private room or other pt with same infection -Gloves and gowns

RN is caring for client with Type 2 DM. Which nursing interventions for stress, coping, & adherence to treatment plan would be appropriate?

Allow client to provide input in treatment plan Assist client with time management & address client's priorities Encourage client to express

Client scheduled for hysterectomy had not yet signed consent form what should the nurse do?

Ask the client why she has changed her mind

Nurse plans diversionary activities for children on ped unit. Appropriate activities for preschoolers?

Assemble puzzles, using musical toys, color with crayons

Follow up assessment

Assess 15-30 minutes after application and regularly thereafter -Assess VS, anxiety level, color, ease of respirations. -Provide support while client adjusts -Assess for signs of hypoxia, tachycardia, confusion, dyspnea, restlessness, and cyanosis. -Review oxygen saturation or ABG results

A nurse on a medical-surgical unit is admitting a client. Which of the following info should the nurse document in the client's record first?

Assessment, then plan of care, then interventions performed, then evaluation of progress.

RN is caring for 16-year-old PT with multiple injuries. He has been combative & impulsive & has pushed RN away and climbed over the side rails. Which nursing intervention best ensures the safety of the client?

Assign a staff member to sit with the client around the clock.

Nurse is caring for client who is having difficulty breathing and has nasal canula. Which intervention is nurse priority?

Assist client to Fowler's position

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss?

Attempt to increase the client's self-motivation: Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.

6 ethical principles

Autonomy Beneficence Nonmaleficence Justice Fidelity Veracity

A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals signatures me the nurse legally witness (select all that apply) A) a teacher who brings in a seven-year-old student B) a 16-year-old client who is married C) a 27-year-old client with schizophrenia D) and adoptive parent who brings in his eight-year-old son E) a 17-year-old mother who brings in her toddler

B) a 16-year-old client who is married C) a 27-year-old client with schizophrenia D) and adoptive parent who brings in his eight-year-old son E) a 17-year-old mother who brings in her toddler

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A) contact B) droplet C) airborne D) protective

B) droplet

A nurses caring for a client who is post operative and has signs of hemorrhagic shock. When the nurse notifies the surgeon he directors her to continute to measure the clients vital signs every 15 minutes and call him back in one hour. From a legal perspective which of the following actions should the nurse take next A) document the provider's statement in the medical record B) notify the nurse manager C) consult the facilities that risk manager D) complete an incident report

B) notify the nurse manager

A nurses caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) carry a clients soil linens out of the room in a mesh linen bag B) place a client who has tuberculosis in a room with negative pressure airflow C) provide disposable plates and utensils for a client who is HIV positive D) dispose of the clients blood saturated dressing in a trash bag inside a second trash bag

B) place a client who has tuberculosis in a room with negative pressure airflow

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? A) regulate the flow rate by aligning the rate with the top of the ball inside the flowmeter B) regulate auction oxygen via nasal cannula out of low rate of no more than 6 L C) make sure the reservoir bag of a partial rebreathing mask remains deflated D) use petroleum jelly to lubricate the client's nares, face and lips

B) regulate auction oxygen via nasal cannula out of low rate of no more than 6 L

A nurse is educating a client who has a terminal illness about her request to decline recipe cetacean and her living well. The client asked what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? A) we will determine who the durable power of attorney for healthcare form as designated B) we will apply oxygen through a tube in your nose C) will ask if you've changed your mind D) we will insert a breathing tube wow we evaluate your condition

B) we will apply oxygen through a tube in your nose

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client? (Select al that apply) A. Talk to the interpreter about the family while the family is in the room B. Ask the family one question at a time C. Look at the interpreter when asking the family questions D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk

B- Ask the family one question at a time D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk

A nurse is planning care for a patient who is a devout Muslim and in 3 days postoperative following a hip arthroplasty. The client is scheduled for 2 physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? A. I will make sure the menu includes kosher options B. I will discuss the daily schedule either the client to make sure the client will have time for prayer C. I will make sure to use direct eye contact when speaking with this client D. I will make sure daily communication is available for this client

B- I will discuss the daily schedule with the client to make sure the client will have time for prayer

A nurse educator is teaching a class on culture and food to a group of newly hired nurses. Which of the following statements indicates an understanding of the teaching? A. Clients who practice Roman Catholicism do not drink caffeinated beverages B. Clients who practice Orthodox Judaism do not eat meat with daily products C. Clients who are Mormon eat only protein of animals that are slaughtered under strict guidelines D. Clients who practice Hinduism do not eat dairy products

B- clients who practice Orthodox Judaism do not eat meat with daily products

Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client. B. Encourage the client to communicate his feelings and thoughts C. Give the nurse client communication no time limits D. Allow communication to occur spontaneously throughout the nurse client relationship

B- encourage the client to communicate his thoughts and feelings

A nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motorcycle crash. Which of the following values indicates the client is in a catabolic state? A. Serum albumin 3.5 g/dL B. Negative nitrogen balance C. BMI of 18.5 D. Serum prealbumin 15 mg/dl

B- negative nitrogen balance

A nurse is caring for a client who states " I have to check with my wife and see if she thinks I am ready to go home." The nurse replies "how do you feel about going home today?" Which clarification technique is the nurse using to enhance communication either the client. A. Pacing B. Reflecting C. Paraphrasing D. Restating

B- reflecting

A nurse is caring for a school aged child who is sitting in a chair. To facilitate effective communication m, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture

B- sit at eye level with the child

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "The pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "The pain makes me feel nauseous."

B. "The pain is like a dull ache in my stomach."

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation? A. "We are not worried. We still have hope that everything will be okay." B. "This is a difficult time, but we are helping each other through this." C. "After he comes home, we can plan our family reunion." D. "We do not need to talk about funeral arrangements at this time."

B. "This is a difficult time, but we are helping each other through this."

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

B. 0.3 mg

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPPA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse B. A nurse asks a nurse from another unit to assist with her documentation C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care D. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside

B. A nurse asks a nurse from another unit to assist with her documentation

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider? A. Fluctuation of drainage in the tubing with inspiration B. Continuous bubbling in the water seal chamber C. Drainage of 75 mL in the first hour after surgery D. Several small, dark-red blood clots in the tubing

B. Continuous bubbling in the water seal chamber Rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while she is waiting for instructions from the provider.

A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased oxygen saturation C. Urinary retention D. Increased pain level

B. Decreased oxygen saturation Rationale: Using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia due to airway obstruction.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A. Request that a respiratory therapist discuss the technique for incentive spirometry B. Determine the reasons why the client is refusing to use the incentive spirometer C. Document the client's refusal to participate in health restorative activities D. Administer a pain medication to the client

B. Determine the reasons why the client is refusing to use the incentive spirometer

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds

B. Elevated temperature Rationale: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow at the back and over the chest to support the arm B. High-Fowler's position with the arms supported on the over-bed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the head of the bed elevated to 15°

B. High-Fowler's position with the arms supported on the over-bed table Rationale: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the over-bed table.

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask

B. Nonrebreather mask Rationale: The nurse should use a non-rebreather mask for a client in respiratory distress to provide the highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

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? A. Insert the catheter at a 45 degree angle B. Place the client's arm in a dependent position C. Shave excess hair from the insertion site D. Initiate IV therapy in the veins of the hand

B. Place the client's arm in a dependent position

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider. A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pursed-lip breathing with exertion

B. Productive cough with green sputum Rationale: When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk taking D. Creativity

B. Responsibility

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resuscitation bag with 80% oxygen prior to the procedure B. Select a suction catheter that is half the size of the lumen C. Place the end of the suction catheter in water-soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mmHg

B. Select a suction catheter that is half the size of the lumen

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? A. Critical pathway B. Situation, background, assessment, and recommendation (SBAR) C. Transfer report D. Medication administration record (MAR)

B. Situation, background, assessment, and recommendation (SBAR)

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings B. Tell the client to keep the head of the bed elevated at least 30 degrees C. Make sure the enteral formula is at room temperature D. Wipe the top of the formula can with alcohol

B. Tell the client to keep the head of the bed elevated at least 30 degrees

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the clients acute pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply) A. The client seems easily agitated B. The client is nonadherent with coughing, deep breathing, and dangling C. The client may have pain medication every 4-6 hr but accepts it every 6-7 hr D. The client reports tenderness in his right lower leg E. The clients vital signs are heart rate 124/ min, respiratory rate 22/ min, temp 98.6 and blood pressure 156/80

B. The client is nonadherent with coughing, deep breathing, and dangling C. The client may have pain medication every 4-6 hr but accepts it every 6-7 hr E. The clients vital signs are heart rate 124/ min, respiratory rate 22/ min, temp 98.6 and blood pressure 156/80

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A. Ask the client to consider a direct donation B. Withhold the blood transfusion C. Request a consultation with the ethics committee D. Ask the client's family to intervene

B. Withhold the blood transfusion

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Ensure sterilization of non-disposable items with ethylene oxide B. Wrap monitoring cords with stockinette and tape them in case C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication D. Wear hypoallergenic later gloves that contain powder

B. Wrap monitoring cords with stockinette and tape them in case

Diabetes blood glucose

BG > 200 mg/dl = hyperglycemia BG < 70 = hypoglycemia urine glucose testing: used to test for ketones in urine. recommended for diabetic patients during times of illness, stress, or when they have a blood glucose > 240

what factors increases the risk of incontinence?

BPH, childbirth, older adults-loss of muscle tone, inefficiency of emptying bladder, nocturia, pregnancy, diet (caffiene, alcohol), poor abdom muscles and pelvic muscles, spinal cord injury, immobility,

CNA

Bathing, Ambulating, Measuring vital signs

In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will?

Be at an increased susceptibility for infection

RN transferring client from bed to chair. To avoid back injury Rn should

Bend at knees maintain wide stance and straight back. Clients hands on nurse shoulders and Rn's hands under clients under arm.

Offer med to post-op patient before ambulation

Beneficence

11. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Bounding pulse Rationale: Bounding pulse is an expected finding of fluid volume excess.

Cane Walking

C - Cane O - Opposite A - Affected L - Leg

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? A) insert the IV catheter into the back of the clients hand B) massage the area of the venipuncture site vigorously C) Insert the IV catheter without using a tourniquet D) apply traction to the skin proximal to the insertion site to stabilize the vein

C) Insert the IV catheter without using a tourniquet

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove IV catheter? A) small air bubbles are in the IV tubing B) IV flow stops when the client bends her arm C) swelling and coolness are observed at the IV site D) blood is visible in the IV catheter and tubing

C) Swelling and coolness are observant IV site.

A nurse is performing a skin assessment of the patient client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as possible indications of the skin malignancy? A) uniform pigmentation B) a regular border C) and uneven shape D) a diameter smaller than 6 mm

C) and uneven shape

A nurse is administering 1 L of 0.9 sodium chloride to a client who is post operative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication of the treatment was successful? A) increased him adequate B) increase in respiratory rate C) decrease in heart rate D) decrease in capillary refill

C) decrease in heart rate

A client who is postoperative is verbalizing pain as a two on the pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication of the client understands the preoperative teaching she received about the pain management? A) I think I should take my pain medication more often since it's not controlling my pain B) breathing faster will help me keep my mind off the pain C) it might help me to listen to music when I'm lying in bed D) I don't want to walk today because I have some pain

C) it might help me to listen to music when I'm lying in bed

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include? A. "Ringing in the ears is an adverse effect of this medication." B. "Have your skin test repeated in 4 months to show a positive result." C. "Expect your urine and other secretions to be orange while taking this medication." D. "Remember to take this medication with a sip of water just before your first bite of each meal."

C. "Expect your urine and other secretions to be orange while taking this medication." Rationale: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur including jaundice, fatigue or malaise.

A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the test quickly."

C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma." B. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage." C. "I should remove the old twill ties after the new ties are in place." D. "I should apply suction while inserting the catheter into my tracheostomy tube."

C. "I should remove the old twill ties after the new ties are in place." Rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A. Blood pressure B. Capillary refill C. Arterial blood gases D. Heart rate

C. Arterial blood gases Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? A. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube

C. Artificial airway cuff leak Rationale: An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing the old dressing B. Warm the irrigation solution to 40.5 degrees Celsius (105 degrees Fahrenheit) C. Cleanse the wound from the center outward D. Use a 20 mL syringe to irrigate the wound

C. Cleanse the wound from the center outward

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal kit C. Container of sterile water D. Nonadherent pads

C. Container of sterile water Rationale: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first. A. Provide the client with a glass of water B. Assist the client to a sitting position. C. Explain the procedure to the client D. Measure the length o tubing to be inserted.

C. Explain the procedure to the client

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? A. Touch the face with a cotton ball B. Apply the vibrating tuning fork to the client's forehead C. Have the client stand with her arms at her side and her feet together D. Perform direct percussion over the area of the kidneys

C. Have the client stand with her arms at her side and her feet together

A nurse in a nutritional clinic is calculating body mass index (BMI) for several clients. Which of the following BMI represents an overweight client? A. 24 B. 30 C. 27 D. 32

C. Overweight is defined as an increased body weight in relation to height, indicated by a BMI of 25-29.9 Chapter 3

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3° C (99.1° F)

C. Persistent cough Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is persistent cough because this indicates a tension pneumothorax, which is a medical emergency.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? A. Schedule respiratory treatments following meals. B. Have the client sit up in a chair for 2-hr periods three times per day. C. Provide a diet that is high in calories and protein. D. Combine activities to allow for longer rest periods between activities.

C. Provide a diet that is high in calories and protein. Rationale: The nurse should provide the client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. Blood pressure 144/82 mmHg

C. Rapid heart rate

A nurse is caring for a client who requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take? A. Apply the stockings so the creases are on the side of the leg B. Apply the stockings while the client's legs are in a dependent position C. Remove the stockings at least once per shift D. Remove the stockings while the client is sitting in a reclining chair

C. Remove the stockings at least once per shift

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? A. Role ambiguity B. Sick role C. Role overload D. Role conflict

C. Role overload

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

C. Skin blanching

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position B. Instill 15 mL of irrigation fluid into the catheter with each flush C. Subtract the amount of irrigant used from the client's urine output D. Perform the irrigation using a 20 mL syringe

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

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? A. Hyperkalemia B. Dyspnea C. Tachycardia D. Candidiasis

C. Tachycardia The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

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? A. The top of the cane is parallel to the client's waist B. When walking, the client moves the cane 46cm (18 in) forward C. The client holds the cane on the stronger side of her body. D. The client moves her stronger limb forward with the cane

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

A nurse is caring for an Asian client who has hypertension. Which of the traditional Asian dietary patterns places the client at risk for this condition? A. Incorporation of plant based foods in the diet B. Consumption of raw fruits C. Preparation of foods using sodium D. Focus on shellfish in the diet

C. The preparation of foods using sodium places the client at risk for hypertension. Many spices in the Asian diet contain sodium, or it is used as a preservative. Sodium consumption should be in moderation.

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? A. You will do great! You just have to get used to it. B. Why are you worried about going home? C. Your daily routines will be different when you get home D. Tell me about your support system you'll have after you leave the hospital E. Let me tell you about a friend of mine with a colostomy who enjoys swimming

C. Your daily routines will be different when you get home D. Tell me about your support system you'll have after you leave the hospital E. Let me tell you about a friend of mine with a colostomy who enjoys swimming

conductive vs sensorineural hearing loss

CONDUCTIVE: issue in middle ear that blocks sound waves from reaching inner ear. -causes: packed cerumen, tympanic membrane damage (r/t middle ear infection), old age (otosclerosis) -Rinne test: bone conduction > air conduction -Weber test: lateralizes to unaffected ear SENSORINEURAL: issue in inner ear or auditory nerve CN8 -Causes: ototoxic meds (gentamycin, furosemide, NSAIDS), excess exposure to loud sounds, old age. -Rinne: air conduction > bone conduction -Weber: lateralizes to unaffected ear

Pursed-lip breathing

COPD, May help alleviate dyspnea -Help control breathing to take nice deeper more effective breaths Helps maintain positive pressure and promotes gas exchange by popping open the alveoli that may have collapsed. -Pt purse lips as if about to whistle and blow slowly and purposefully without puffing cheeks, tightening abdominal muscles while breathing to assist with exhalation. count to 7 when SOB increase 5-10 minutes 4 times a day

A client who has type 1 diabetes is schedule for appendectomy and has been NPO since midnight. There are no preop orders for a daily insulin dose. Which intervention is appropriate

Call the provider to request an insulin prescription

Nurse is inserting IV catheter for client that results in blood spill on her gloved hand. Client has no documented bloodstream infection. Which of the following actions should the nurse take? Wash gloved hands and then throw away gloves Prepare an incident report to document the vent Carefully remove the gloves and follow with hand hygiene Ask a provider to order a blood culture to determine the risk of infection

Carefully remove the gloves and follow with hand hygiene

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene. Do not wash the hands while they are still gloved, and an incident report/ blood culture is not needed unless there is a break in the nurse's skin.

Client fell and sitting in chair now

Chart: Pt fell in shower and was able to get himself back into chair

A nurse is caring for an incontinent individual and is reporting a painful perineum. What should be the primary action of the nurse?

Check the client's perineum

what is idopathic pain?

Chronic pain of unknown origin. Often associated with depression

When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should?

Cleanse the port prior to withdrawing urine.

Nurse is demonstrating post-op deep breathing and cough exercises to client who will have emergency surgery for appendicitis. Which client statement indicates lack of readiness to learn? Client asks for nurse to repeat instructions before attempting exercises client reports severe pain Client asks how often deep breathing should be done post-op Client tells the nurse that this exercise will probably be painful after surgery

Client reports severe pain

hypoxia

Clinical Manifestations of _________: -Rapid pulse -Rapid shallow respirations and dyspnea -Increased restlessness or light-headedness -Raring of the nares -Substernal or intercostal retractions -Cyanosis

Direction to include when testing CN V

Close your eyes Clench your teeth Tell me when you feel a touch

39. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities Rationale: Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent.

A nurse is caring for a client who has just had a mastectomy and has closed wound suction Hemovac place. What nursing action will ensure proper operation of the device.

Collapsing the device whenever it's 1/2 to 2/3rds full of air

A nurse is teaching CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance Begin chest compressions Confirm unresponsiveness Give rescue breaths

Confirm unresponsiveness

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

Confirm unresponsiveness, then call for assistance, begin chest compressions, and give rescue breaths.

18. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit. Rationale: A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit.

You are washing your hands with a nonantimicrobial soap and water prior to repositioning a patient in bed. During the hand washing procedure, it is important to

Continue for at least 15 seconds Hand washing with nonantimicrobial soap and water for at least 15 seconds reduces bacterial counts and can remove loosely adherent transient flora. The CDC recommends rubbing hands together vigorously for at least 15 seconds, covering all surfaces of hand and fingers

Which of the following actions of a newly licensed nurse performing tracheostomy care would require intervention by the charge nurse (must be corrected)? Obtaining hydrogen peroxide for trach care Obtaining cotton balls for trach care Obtaining sterile gloves for trach care Obtaining sterile brush for trach care

Cotton balls- can be aspirated into trach opening

21. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use. Rationale: Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs.

expectorate

Cough up and spit out mucus from the respiratory tract

RN measuring vitals and notices irregular heart beat. Which nursing action is appropriate?

Count apical pulse for 1 full minute and describe the rhythm in chart.

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

Count the apical pulse rate for 1 full minute and describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record. The nurse should assess pedal pulses to determine circulation in the client's lower extremities. The nurse should use a Doppler ultrasound for a pulse that is non palpable or very difficult to palpate. The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.

A nurse notices an irregularity in the pulse when measuring patient's vital signs. Which action should the nurse take? Measure pulse using Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds.

Count the apical pulse rate for 1 full minute, describe the rhythm in the chart.

12. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing. Rationale: The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

Subjective

Current resp. problems Hx of resp. disease Lifestyle Presence of cough Description of sputum Presences of chest pain Presence of risk factors Medication hx

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A) numbness of the extremities B) Bradycardia C) positive Chvostek's sign D) Abdominal cramping

D) abdominal cramping

A nurse is teaching a client about dietary management of hyper cholesterolemia. Which of the following foods should the nurse suggested the client add to his diet? A) beef liver B) shellfish C) egg yolks D) avocados

D) avocados

A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? A) loss of skin turgor on the back of the hands B) varicosities on the lower extremities C) thick, dissolved nails with ridges D) bruises on the arms in various stages of healing

D) bruises on the arms in various stages of healing

A nurse is assessing a client reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? A) is your pain constant or intermittent? B) what would you rate your pain on a scale of 0 to 10? C) does the pain radiate? D) is your pain sharper or dull?

D) is your pain sharper or dull?

The middle adult client tells the nurse "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? A) most people are happy when their children grow up and leave home. B) You should be proud that your children are becoming independent C) maybe you should consider why you are feeling useless D) people in middle adulthood often find satisfaction in nurturing and guiding young people

D) people in middle adulthood often find satisfaction in nurturing and guiding young people

Undersize planning teaching for a group of adolescents who beach recently had surgical placement of an ostomy. Which of the following message to the nurse use as a psychomotor approach to learning? A) role play B) group discussions C) question-answer meetings D) practice sessions

D) practice sessions

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A. "When do you usually bathe, in the morning or in the evening?" B. "Do you prefer a bath or a shower?" C. "At what temperature do you prefer your bath water?" D. "Are you able to help with your hygiene care?"

D. "Are you able to help with your hygiene care?"

A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? A. "I will monitor my heart rate every day while taking this medication." B. "I will make sure I have this medication with me at all times." C. "I will need to carefully rinse my mouth after I take this medication." D. "I will take this medication every night even if I don't have symptoms."

D. "I will take this medication every night even if I don't have symptoms." Rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A. A nurse tied a client's restraint straps to the moveable part of the bed frame B. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology C. A nurse administers a medication to a client 30 minutes before the dose is due D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid

D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? A. Provide a quiet environment. B. Encourage use of incentive spirometry every 1 to 2 hr. C. Obtain a blood sample for electrolyte study. D. Administer heparin via continuous IV infusion.

D. Administer heparin via continuous IV infusion. Rationale: Using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A. Cromolyn sodium B. Prednisone C. Fluticasone/salmeterol D. Albuterol

D. Albuterol Rationale: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? A. Suction the client's airway B. Administer a bronchodilator C.Increase the humidity in the client's room D. Assist the client to an upright position

D. Assist the client to an upright position

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 indicate? A. Protective environment B. Airborne precautions C. Droplet precaution D. Contact precautions

D. Contact precautions

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? A. Dissolve each medication in 5 mL of sterile water B. Draw up medications together in the same syringe C. Push the syringe plunger gently when feeling resistance D. Flush the tube with 15 mL of sterile water

D. Flush the tube with 15 mL of sterile water

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? A. Tomato juice B. Banana slices C. Pancakes D. Fried egg

D. Fried egg

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? A. Assign the client to a room with a negative air-flow system B. Use alcohol-based hand sanitizer when leaving the client's room C. Clean contaminated surface in the client's room with a phenol solution D. Have family members wear a gown and gloves when visiting

D. Have family members wear a gown and gloves when visiting

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? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube B. Remove the NG tube if the client begins to gag or choke C. Apply suction to the NG tube prior to insertion D. Have the client take sips of water to promote insertion of the NG tube into the esophagus

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

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fowler's position B. Increase the client's intake of carbohydrates C. Massage reddened areas with unscented lotion D. Have the client use a trapeze bar when changing position

D. Have the client use a trapeze bar when changing position

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A. Insert an implanted port B. Close a laceration with sutures C. Place an endotracheal tube D. Initiate an enteral feeding through a gastrostomy tube

D. Initiate an enteral feeding through a gastrostomy tube

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24 mEq/L D. Intercostal retractions

D. Intercostal retractions Rationale: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle accident. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make? A. I believe in this case you should really make an exception and accept the blood transfusion B. I know your family would approve of your decision to have a blood transfusion C. Why does your religion mandate that you cannot receive blood transfusions? D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution

D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? A. Arterial pH 7.50 B. PaCO2 25 mmHg C. SaO2 92% D. PaO2 58 mm Hg

D. PaO2 58 mm Hg Rationale: The nurse should expect the client who has acute respiratory failure to have lower partial pressures of oxygen.

A nurse is reviewing a client's fluid and electrolyte status which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D. Potassium 5.4 mEq/L

A nurse is chasing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? a. Sanguineous exudate b. Serous exudate c. Serosanguineous exudate. D. Purulent exudate

D. Purulent exudate

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

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

A nurse working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side

D. Tracheal deviation to the unaffected side Rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? A. Tell the client which food they should eat first. B. Provide small-handle utensils for the client. C. Thicken liquids on the client's tray D. Use a clock pattern to describe food on the client's plate

D. Use a clock pattern to describe food on the client's plate

A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline

D. discipline

A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A. pH 7.50, PO2 95 mm Hg, PaCO2 25 mmHg, HCO3- 22 mEq/L B. pH 7.50, PO2 87 mm Hg, PaCO2 35 mmHg, HCO3- 30 mEq/L C. pH 7.30, PO2 90 mm Hg, PaCO2 35 mmHg, HCO3- 20 mEq/L D. pH 7.30, PO2 80 mmHg, PaCO2 55 mmHg, HCO3- 22 mEq/L

D. pH 7.30, PO2 80 mmHg, PaCO2 55 mmHg, HCO3- 22 mEq/L Rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.

7. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight Rationale: According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement.

A client being discharged following abdominal surgery will be performing his own dressing change most important for the nurse to include which of the following on the discharge plan?

Demonstration of correct hand hygiene

Nursing instructor, various lifespan stages to students. Nurse offers what behavior by young adult as example of appropriate psychosocial development?

Devotes great time to establish occupation.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine beings to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min- if the nurse questions the reliability of monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client so it must be tagged and removed.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take? Turn on the machine every 15 minutes to measure the BP. Record only BP readings needed for the 15-min intervals. Obtain manual and automatic readings & compare them. Disconnect the machine, measure the BP manually every 15 minutes.

Disconnect the machine, measure the BP manually every 15 minutes.

Standard precautions mandate

Disinfecting hands immediately after removing gloves Although it might seem as though hands covered by intact gloves would be as clean as they were when you donned the gloves, it is an essential component of standard precautions to disinfect your hands immediately after glove removal. This often concludes a patient-care procedure, and hand hygiene is mandated between patient contact. Also you cannot assume that the integrity of each glove has not been breached, that no powered or other residue remains on your hands, and that your hands have not been contaminated during glove removal.

Postural drainage

Drainage by gravity of secretions from various lung segments. -Promote lung drainage -2-3 times daily, before meals, 10-15 minutes -Monitor pulse and respiratory rates, pallor, diaphoresis, dyspnea, nauseas, and fatigue

Hypoxemia symptoms

EARLY: restless irritability tachypnea tachycardia increased BP pallor abnormal breathing LATE: decreased LOC (stupor) bradycardia dysrhythmias bradypnea decreased BP cyanosis

EYE assessment

EOM: corneal light reflex: shine light on eyes, check for symmetry on corneas cover/uncover test: tests for strabismus check 6 cardinal gaze positions by having pt follow your finger as you make a large "H" patten in front of them PERRLA: pupils clear, equal to 3-7 mm diameter, round, reactive to light, accommodation to far and near objects artery / vein ratio: 2:3

3. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults Rationale: Primary prevention includes health education about disease prevention.

A nurse is caring for a client diagnosed with terminal illness. Client asks several questions about nurse's religious beliefs the nurse should respond by

Encourage client to express his thoughts about death & dying

A nurse is caring for a client who has a terminal illness. The client asks several questions regarding the nurse's religious beliefs related to death and dying. How should the nurse respond? Change the topic because the client is trying to divert attention from the illness. Encourage the client to express his thoughts about death and dying. Tell the client that religious beliefs are a personal matter. Offer to contact the client's minister or facility's chaplain.

Encourage the client to express his thoughts about death and dying.

RN recognizes that a helping relationship is established client if the communication is:

Encourages the client to express his thoughts & feelings.

A client is admitted for evaluation and control of hypertension. Several hours the client's admission, the nurse finds the client supine on the flour on the floor unresponsive. The nurses first action at this time should be

Establish airway

RN enters PT's room and finds PT in respiratory arrest. First action the RN should take is

Establish an open airway.

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

Evaluate pedal pulses. For a client with decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. The ABC priority-setting framework. Obtaining a medical history, measuring the vital signs, and assessing for the leg pain all come next.

3 yr old has had multiple extractions under general anesthesia. Client returns form post anesthesia crying what approach is likely to be successful

Examine the mouth last

Pt reports when RN evaluates internal rotation of her R shoulder. Which activities is this problem likely to affect?

Fastening her bra behind her back

45. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity Rationale: The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

Nurse teaching clients how to administer meds via j-tube. Which instructions should nurse include in teaching?

Flush the tube before & after each med

23. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin Rationale: Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature.

You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body

Gently pulling the pinna back and upward -A tympanic thermometer is probably not the best choice when the patient's ears show signs of infection, inflammation, or trauma because of the risk of further damage, pain, or contamination. But the device would still register temperature accurately.

After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which should the nurse remove first when removing PPE separately?

Gloves Gloves are considered the most contaminated and should be removed first, followed by face/eye protection, gown, and mask/respirator

RN is caring for client admitted to hospital with high fever, chills, & dehydration. The RN knows that which lab test will not help the provider confirm infection

Glucose

An ED nurse is assessing a client who reports diarrhea and decreased urination for 4 days. Which action should the nurse take to assess for skin turgor- results from dehydration? Push fingernail bed until it blanches, release, observe how long it takes for it to regain color. Grasp a skin fold on chest under clavicle, release, not whether tenting occurs. Press skin in above ankle for 5 seconds, release, note the depression. Measure skin fold thickness at upper arm using calipers.

Grasp a skin fold on chest under clavicle, release, not whether tenting occurs.

A nurse in the ER is assessing a client who reports diarrhea and decreased urination for 4 day.s Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp the skin fold on the chest under the clavicle, release it, and note whether it springs back. The nurse should used this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm. Pushing on the fingernail bed until it blanches and seeing how long it takes to return to pink in color assesses capillary refill. Pressing the skin in above the ankle for 5 seconds, releasing it, and noting the depth of the impression determines the extent of pitting edema. Measuring the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers assesses the client's body fat percentage.

22. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning?

Have the client demonstrates the procedure. Rationale: Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.

A client is taking several med to treat CHF & rheumatoid arthritis arrives at clinic with fatigue, anorexia, & nausea. Which assessment question is the nurse's priority?

Have you been taking your meds as prescribed?

Priority to parents of school age child?

He doesn't keep up with their kids in activities like running and jumping

Older client was diagnosed with colon cancer asks RN what primary care provider has planned. Provider will be making rounds within the hr. What nursing action is appropriate?

Help the client write down questions to ask the provider so that they don't forget

40. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic Rationale: A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

AP tells nurse " I am not able to find a large bp cuff for an obese pt. Can I use a regular sized one if it stays on? The nurse replies with if you do that the BP will be

High

Which instructions should nurse give for transferring her blood onto reagent portion of the test strip?

Hold test strip next to blood on fingertip

When changing the linen on a client's bed, the nurse should?

Hold the linen away from his body & clothing

What action prevents injury to client's eye during administration of eye drops?

Holding the tip of the container above the conjunctival sac

Maintaining a clear airway and effective gas exchange

Home care oxygenation: -No smoking -Effective coughing techniques -Discuss significance of changes in sputum -Maintain fluid intake of 2500 mL -Instruct pt how to use nebulizers or inhalers -Instruct how to use home O2 delivery systems

pre-op mastectomy teaching. which indicates pt is ready to learn

How long will the surgery take?

Kussmauls breathing

Hyperventilation that accompanies metabolic acidosis. Body attempts to compensate for increased metabolic acids by blowing off acid in the form of CO2

Alterations in respiration

Hypoxia Altered breathing patterns Obstructed airway

Client is about to have NG inserted and RN is about to begin with client say 'No Way! You're not putting that hose down my throat. Get away from me!" Which of the following statements is an appropriate response?

I can see that this is upsetting you.

Receiving dextrose 5% in 0.9% NaCl IV at 120 mL/hr. Which of the following statements should alert RN to suspect fluid overload?

I feel as through my heart is racing I feel a little SOB The nurse's aide told me that my BP was 150/90

A nurse in oncology clinic is assessing pt. undergoing treatment for ovarian cancer. Which statement indicates she is undergoing psychological distress? My parents are retired and they have to come help me with children I'm going to ask my husband to go to counseling with me. I keep having nightmares about my upcoming surgery My girlfriends bought me a nice wig

I keep having nightmares about my upcoming surgery

reviewing care of pt w/ seizure, need more instruction

I will leave pt and get help

A client just returned from a hysterectomy and asks for something drink. She is on a clear liquid and advanced diet. Which is the most appropriate for the nurse to tell the client?

I'm going to listen to your abdomen

Tertiary Care

ICU, Oncology Tx Center, and Burn Center

Nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which action should the nurse take FIRST? Explain procedure to client. Help client into wheelchair before the transporter arrives Ask if client has any questions Identify the client using 2 identifiers

Identify the client using 2 identifiers

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

Identify the client using two identifiers: Other choices: explain the x-ray procedure to the client, help the client into a wheelchair before the transporter arrives, and ask if the client has any questions.

PT has a prescription for diazepam. Which action is highest priority?

Identifying client's med allergies

29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines Rationale: Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis.

metabolism

Inactivation of meds by enzymes. happens in liver primarily, but also in kidneys, lungs, intestines affected by: -age: infants and elderly have decreased metabolism, resulting in higher risk of toxicity -First-pass effect: some meds are inactivated on their first pass through the liver, and must be administered through parenteral route. -some meds can affect the metabolism of other meds -poor nutrition can decrease metabolism

complete obstructed airway

Indicated by extreme inspiratory effort with no chest movement

partially obstructed airway

Indicated by low-pitched snoring during inhalation

Contact precautions would be mandated for a hospitalized adult patient diagnosed with

Infectious diarrhea Contact precautions are essential for preventing the spread of certain enteric infections. These precautions mean no direct touching of the patient, the environment, the equipment, or the supplies used. The patient should be in a private room.

Phases of wound healing

Inflammatory (3-6 days): vasoconstriction, clot formation, hemostasis. Phagocytosis of micro organisms Proliferative (3-24 days): replacement of lost tissue with granulation tissue and collagen, wound contraction, wound resurfacing (with new epithelial cells) Maturation (1+ years): remodeling and strengthening of collagen tissue

Which nursing action demonstrates safe principles of administrating a routine immunization to an infant?

Inject the vaccine into the vastus lateralis muscle.

Appropriate action when assessing adult client's internal ear canal with otoscope?

Insert speculum down and forward Speculum doesn't touch ear canal Visualize tympanic membrane in cone shape

normal order of assessment

Inspect, Palpate, Percuss, Auscultate

8. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection Rationale: According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps.

Ineffective breathing pattern

Inspiration and or expiration that does not provide adequate ventilation

5 yo whose parent report fear of shot, how to ease fear?

Invite to assist with mealtime activities, bring fave toy from home, pretend play with toy medical kit.

RN is teaching client who has CVD how to reduce his intake of sodium and cholesterol. Rn knows that most significant factor in the planning process is

Involvement of the client in planning the change

lower airway obstruction

Involves partial or complete occlusion of the passageways in the bronchi and lungs most often due to increased accumulation of mucus or inflammatory exudate

Which of the following manifestations should alert the RN to possibility of early hypovelemic shock?

Irritability (also anxious, nervous per ATI)

AP says to nurse, "Clint is incontinent of stool 3-4 times a day. I get angry, and thin that they are doing it for attention." Which is the appropriate nursing response

It's very upsetting to see an adult client regress

Which of the following is an advantage of using alcohol-based gel?

Its use takes less time than washing with soap and water does. During an 8 hour shift, an estimated 1 hour of an intensive care unit nurse's time is saved by hand rubbing with an alcohol-based gel

A client had a hiatal hernia repair 3 days ago. During AM, client says abd feels swollen, I'm nauseated, and I'm in abd discomfort. What should nurse's initial action be?

Listen for bowel sounds

13. A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver Damage Rationale: Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.

41. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss Rationale: At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

maturational loss

Loss, usually of an aspect of self, resulting from the normal changes of growth and development.

2. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head. Rationale: To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head.

maturational loss vs situational loss

M: loss expected with normal life S: unexpected, external event

error prone abbreviations that should NOT be used

MS,MSO4 for morphine MgSO4 for magnesium sulfate decimal points without leading 0 trailing zerio U,U,IU for units qd,q.d. for daily qod, q.o.d for every other day SC, SQ, subq for subcutaneously

Which are active listening?

Maintain open posture Establishing & maintaining eye contact Responding positively when giving feedback

PT is transported to PACU. Abd dressing is dry, IV fluids are infusing. Which of the following is a priority nursing goal at this time?

Maintaining a patent airway

Diarrhea & Vomiting

Metabolic Acidosis: From the ass / Diarrhea Metabolic Alkalosis: From the mouth / Vomit

a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client?

N95 respirator

ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, activity intolerance

NANDA includes the following diagnostic labels for clients with oxygenation problems:

key points with insulin admin

NEVER MIX LONG-ACTING INSULIN (INSULIN GLARGINE) CLEAR BEFORE CLOUDY -inject air into longer acting insulin (NPH) -air into shorter-acting (regular) -draw up clear shorter-acting -draw up longer-acting cloudy

sleep cycles

NREM (non-REM): -stage 1: very light sleep, VS and metabolism start to decrease, few mins long -stage 2: deeper sleep, VS and metabolism continue to decrease, 10-20 mins long -stage 3: beginning of deepest sleep, difficult to awaken. 15-30 mins long -stage 4: deepest sleep, provides physiologic rest and restoration VS low, very difficult to awaken. Sleepwalking/talking possible. 15-30 min long REM: provides cognitive restoration, vivid dreaming, very difficult to awaken, variable VS. 20 min long.

Positive PPD

Needs to be verified with a chest x-ray

Blood pressure classifications

Normal: 120/80 Prehypertension: 120-139/ 80-89 Stage 1: 140-159/ 90-99 Stage 2: >160/ >100 DM or kidney disease will tx in prehypertension

A nurse is prepping a client who is scheduled for a hysterectomy for transport to OR when the client states she no longer wants to have surgery. Which action should nurse take? Tell client it is too late to change her mind before surgery Telephone OR and cancel surgery Inform client's family about situation Notify provider about client's decision

Notify provider about client's decision

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take first?

Notify the provider about the client's decision. Acting as the client advocate, the nurse should support the client in her decision and notify the provider. The nurse should respect the client's confidentiality and not notify the family of the situation, and the nurse cannot take on the responsibility of telephoning the OR and canceling the surgery. The client has the right to refuse a procedure after giving consent.

A Nurse makes an initial assessment of a client who is postoperative following a gastric resection, the client's nasogastric tube is not draining. The nurse's attempt to irrigate the tube with 0.9 % 10 ml saline. The irrigation is unsuccessful and the nurse determines that the NG tube is blocked. What is the nurses next action?

Notify the surgeon

Nurse is administering aspirin 81 mg PO daily as prescribed. Med is schedules for 0800 hours. Which demonstrates proper use of 1 of the "6 Rights" of med. admin?

Nurse identifies pt. w/ name as written on med. admin record (WRONG) **documentation

Nurse on a med-surg unit is washing her hands prior to assisting in a surgical procedure. Which action indicates proper surgical handwashing? Nurse washes each part of her hands with 5 strokes Nurse washes from elbows down to hands Nurse washes with hands held higher than elbows Nurse uses minimal friction when washing her hands

Nurse washes with hands held higher than elbows

Eyes

OU: Both eyes OS: Left eye OD: Right eye

You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration you

Observe the patient's chest movements while appearing to assess his pulse -You are mostly likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

1. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations. Rationale: The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.

Rn caring for client with HTN. Which approach is priority when measuring BP

Obtain BP under same conditions each time

Client who requires rectal temp. long, slender tip is available which of the following is appropriate action

Obtain a thermometer with a short, blunt insertion end

Which action should nurse take first when using nursing process to care for a new client? Identify goals for client care Obtain client information Document nursing care needs Evaluate effectiveness of care

Obtain client information

A nurse on a med-surg unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information, document nursing care needs, then identify goals, then evaluate the effectiveness of care.

To use nursing process correctly nurse should first

Obtain information about the client

A charge nurse is observing a newly licensed nurse perform a tracheotomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy care- cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene. Half-strength peroxide solution is used to clean the inner cannula, and tracheostomy care is a sterile procedure requiring the use of sterile gloves. Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula.

A client has fecal impactation. What kind of enema should be used to loosen the impaction?

Oil Retention

34. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention Rationale: The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client.

Strategies for client as first step of comprehensive physical exam?

Open & close question, reduced environmental noise, general survey before exam

Right lower quadrant

Over which abdominal quadrant are bowel sounds most active and therefore easier to auscultate?

dehydrates

Oxygen administered from a cylinder or wall outlet system is dry. Dry gases __________ the respiratory mucous membranes and can cause discomfort and nosebleeds in pts.

palliative vs hospice care

P: interventions focus on symptom relief. can be given at the same time as treatments to cure dz, or during end of life H: for patients with a terminal illness, not expected to live more than 6 months. focus is on symptom relief, not curing dz

15. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals Rationale: The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation.

5 IV complications

PHLEBITIS: Symptoms: erythema, pain, warm, edema, indurated, cordlike veins, red stream -D/C IV, elevate extremity, warm compress, obtain specimen for culture if indicated INFILTRATION: symptoms: swelling around site, edema, coolness, dampness, slowed rate of infusion D/C IC, elevation, warm/cold compress CATHETER EMBOLUS: symptoms: missing catheter tip when removing IV, severe pain with migration -tourniquet high on extremity, prepare pt for removal of tip w/ x-ray or surgery FLUID OVERLOAD: symptoms: increased BP, JVD, tachy, SOB, crackles, edema CELLULITIS: symptoms: pain, warm, edema, induration, red streak, fever, chills, malaise

percussion, vibrations and postural drainage

Performed according to primary care providers order by nurses, respiratory therapist, and physical therapist

The nurse auscultates a high-pitched scratching sound during diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

Pericardial friction rub

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worst with inspiration. The nurse asucultates a high-pitched scratching sound during both sytstole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub- A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with MI, following cardiac surgery or trauma, and with some autoimmune problems such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. Audible click is a sound occurring in clients who have prosthetic valve replacements surgery. A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through the valves or ventricular outflow tracts. Low-and medium- frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease. A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best head at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates HF.

Which product affect the permeability of gloves?

Petroleum-based hand lotion The use of petroleum-based hand lotions or creams can impair the integrity of latex gloves, weakening them and increasing their permeability.

Client in ER reporting having diarrhea for 4 days and urinating less RN should

Pinch under clavicle, release it and note if it springs back

The nurse recognizes that the client is choking. When performing the Heimlich maneuver on a conscious client, which nursing action is effective?

Place both arms around the client, and position a fist in between the bottom of the sternum and the naval

To use proper body mechanics while making an occupied bed the nurse should

Place the bed in a high horizontal position

Nurse is obtaining BP in client's lower extremity. Which of the following actions should the nurse take? Ausculate for BP at dorsalis pedis artery Measure BP with client sitting at edge of bed. Place cuff 3 in above popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh

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

Nurse plans presentation for older adults for screening test and preventative procedures for this stage of life?

Pneumococcal immunization, eye exams, mental health screening, dual energy xray scan(DEXA)

31. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side. Rationale: Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.

Provider orders cleansing enema for client. Which nursing intervention is appropriate during this procedure?

Position the client on his side.

oxygen therapy

Prescribed by primary care provider who specifies deliver method, flow and concentration. -Nurse may initiate during an emergency without an order -Dangerous because facilitates combustion -Colorless, tasteless, odorless

_____ prevention: keeping healthy people healthy

Primary

intentions of wound healing

Primary intention: wound edges approzimated (sutures/staples). Heals quickly, minimal scarring Secondary intention: wound edges widely separated. Longer healing time, scarring, increased infection risk. Tertiary intention: wound left open to address infection and then closed at a later time.

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must

Protect your eyes Droplet transmission involves contact of infectious, large-particle droplets with the conjunctivae or the mucous membrane of the nose or mouth of a susceptible person. Droplets are generated by the patient during coughing, sneezing, or talking, and during procedures such as suctioning and bronchoscopy

38. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day. Rationale: A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.

Pain mgmt is inadequate

Pt is nonadhere to coughing & deep breathing Client accepts med every 6-7 hrs, despite it being 4-6 hrs Vitals: 110 min, 20 resp rate, BP 136/80

good lung down

Pts with sever pneumonia or other pulmonary disease in one lung, if positioned laterally, should be positioned with the _______ _______ ______ to improve diffusion of oxygen to blood from functioning alveoli

Nurse is preparing to instill antibiotic ear drops into toddler's ear. Which technique should be used?

Pull pt's auricle down and back to open canal when administering drops

RN is caring for client on strict bed rest. When entering, RN notices flames in waste basket. The priority action is:

Pull the client into the hall in the bed

Trach Tube Cuff

Purpose of the cuff decreases the chance of aspriation into the trachea

A nurse is caring for postoperative cholecystectomy client. The nurse observes dressing that is yellow and thick. What type of drainage is this?

Purulent

10 rights of safe med admin

RIGHT: patient medication dose time route documentation patient education refuse assessment (before/after admin) evaluation

assessment focuses for mobility

ROM, gait, exercise status, activity tolerance, body alignment w/ standing, sitting and lying

A nurse is performing mouth care for unresponsive client. Which action should nurse plan to take? Place client supine Keep both side rails up Raise level of bed Inspect client's mouth using finger sweep

Raise level of bed

A nurse is to perform mouth care for a unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed. Client should be side-lying, not supine, and the side rail closest to the nurse should be lowered. The nurse should never insert her fingers into the mouth of the unresponsive client.

Tachypnea

Rapid respirations, is seen with fevers, metabolic acidosis, pain and hypoxemia.

Objective

Rate Depth Rhythm Quality Positioning of client Shape of thorax (barrel chest) Bulges, tenderness, abnormal movements Auscultation

Older adult that can't cook meals at home?

Refer to Social Worker

Pt says I'm ready to be discharged. RN says How do you feel about going home? Clarifying technique is nurse displaying to enhance communication?

Reflecting

A nurse is collecting a liquid stool specimen to check for ova and parasites. What would cause an error in this test?

Refrigerated the collected specimen

_____ risk that involves comparison between two groups

Relative

The provider prescribes soft wrist restraints for an older adult client who is violent and attempting to pull out IV lines. Which action is appropriate for client in restraints? Tie restraints to side rails Perform wrist ROM every 3 hr Remove restraints one at a time Obtain PRN order for restraints

Remove the restraints one at a time

36. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher. Rationale: Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first.

deep breathing and coughing

Removes secretions Encourage the pt to expectorate Breathing exercises Coughing techniques

20. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion five times during each session. Rationale: To maintain the client's joint mobility the nurse should repeat each motion three to five times.

water soluble lubricant

Required to sooth the mucous membrane while using nasal cannula to treat nares for encrustation and irritation never use petroleum based products (you can also pad the tubing and band over ears and cheekbones to prevent irritation on ears from cannula strap)

Findings nurse should expect when asuculatating & percussing client's thorax

Resonance Tactile Fremitus Bronchovesicular Sounds

Tests to test client's balance?

Romberg test Heel-to-toe walk

balance assessment

Romberg test: have pt stand with hands at side and eyes closed (normal result=no swaying for 5 sec or more) heal to toe walk

frostbite

S&S: white, waxy areas of exposed skin, tissue injury full or partial thickness warm to 38-40 degrees celcius provide pain meds administer tetanus vaccination!

when do the mitral and tricuspid valves close?

S1 heart sound, during systole

when do the aortic and pulmonic valves close

S2 sound, during diastole

Nurse preparing wellnes presentation. When discussing health screening, which info about scoliosis should include.

Scoliosis is more common in girls than in boys Scoliosis screening is essential during adolescent growth spurt.

A community health nurse is preparing a campaign about seasonal influenza. Which plan should nurse include as secondary prevention? Holding community clinic for flu shots Screening groups of older adults in skilled nursing facilities for early signs of influenza Educating parents of young children about dangers of influenza Finding rehab programs for older adults with complications from the flu

Screening groups of older adults in skilled nursing facilities for early signs of influenza

Rn assessing client who reports having a heart murmur due to aortic stenosis. Where do you place the stethoscope to hear the aortic valve

Second intercostal space to the right of the sternum

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum- the aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. The mitral valve is located in the fifth intercostal space just medial to the mid-clavicular line. The pulmonic valve is located in the second intercostal space to the left of the sternum. The tricuspid valve is located in the fifth intercostal space to the left of the sternum.

_____ prevention: intervention after illness. Goal is to slow progress (Ex: Diabetes Foot Exam)

Secondary

A nurse is caring for a client who is in the terminal stage of cancer. Which action should the nurse take when she observes the client crying? Contact family and ask them to stay with the client Offer to call client's minister Sit and hold client's hand Leave the room and allow the client to cry privately.

Sit and hold client's hand

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand- with this action, the nurse uses the therapeutic communication techniques of silence, tough, and offering of self to the client. Do not shift responsibility of helping the client to others, put the client's needs on hold, or fail to acknowledge the client's distress.

42. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client. Rationale: The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding.

Teaching for an older adult who has constipation should include which of the following recommendations? Drink a minimum of 1000 mL fluid daily Increase intake of refined-fiber foods. Sit on toilet 30 minutes after eating a meal Take a laxative every day to maintain regularity

Sit on toilet 30 minutes after eating a meal (To prevent constipation, must drink 1500 mL or more, and increase intake of coarse-fiber foods/whole-grains).

Risks with oxygenation problem

Skin or tissue breakdown Syncope Acid base imbalances Feeling of hopelessness or social isolation

Age related finding on an older adult who's postmenopausal

Smaller nipples More pendulous Nipple inversion

A nurse is collecting a urine specimen for a client to test specific gravity of urine. What does this test measure?

Solutes in Urine

Findings nurse should expect as changes associated with aging?

Some vision & hearing decline Slower find finger movement Some short-term memory decline

Therapeutic index and Half-life

TI: compares the minimum effective concentration (MEC- amount at which the drug is effective) to level at which drug is toxic. -meds with a high TI are safer, no need for close monitoring of blood levels -MEDS WITH A LOW TI REQUIRE CLOSE MONITORING OR BLOOD LEVELS (peak and trough levels). trough levels should be taken right before next medication dose Half-life: amount of time it takes for a medication to be reduced by 50% in body. -med with short half-life leaves body quickly -med with long half-life increases risk of toxicity

T/F Do not put up all 4 side rails for pts who will try to get out of bed on their own

TRUE

After a colon resection for adenocarcinoma, which manifestation would the nurse expect to see if the client were to develop internal abdominal bleeding postop?

Tachycardia

46. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia Rationale: Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.

Smoke

Teach pt never to ______ while oxygen therapy is in progress and teach family members to do it outside

Home care oxygenation

Teach: -Maintaining airway clearance and effective gas exchange -Promoting effective breathing -Medications -Specific measures for O2 problems -Referrals -Community agencies and other sources of healt

A nurse is assessing a client admitted with a sudden onset back pain of unknown origin. Which statement would be most effective for the nurse to elicit further information from his client about his pain?

Tell me how you're feeling

Nurse caring for pt type 1 diabetes. The client is resistant to learn self-injection. Nurse explains importance of learning self care the nurse also add this statement

Tell me what I can do to help overcome your fear

A nurse is caring for a client who has T1DM and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? Tell me what I can do to help you overcome your fear of giving yourself injections. I am sure your provider will not be pleased that you refuse to give yourself injections. It's okay- your partner will be able to learn to give you injections. You won't be able to go home without learning how to give yourself injections.

Tell me what I can do to help you overcome your fear of giving yourself injections.

A nurse is planning the care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temp of 102.6, HR of 105/min, a soft non tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurses's priority?

Temperature

Nurse is obtaining vitals for a 2-year old child who is experiencing diarrhea and may have right ear infection. Which route should be used to measure temperature? Rectal tympanic oral temporal

Temporal- oral temp. is not suitable for kids under 3

17. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder. Rationale: The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.

A nurse is caring for a client who is receiving an IV that has been infiltrated. What would be an unexpected finding when the nurse assess the client's infusion line and insertion site

The area around the injection site feels warm when touched.

altitude

The higher the _______ the lower the PO2

A nurse is providing teaching to a client who has heart failure about how to reduce his sodium intake. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? Involvement of client in planning the change Emphasis provider places on the dietary changes Learning theory the nurse uses to teach the dietary changes The extent of the dietary changes planned for the client.

The involvement of the client in planning the change

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change- according to EBP, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

The nurse should place the bladder of the cuff over the posterior aspect of the thigh- this is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. The nurse should position the cuff 2.5cm above the popliteal artery, measure the blood pressure with the client prone if possible [or supine with the knee flexed] and the nurse should ausculate the blood pressure at the politeal artery.

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

The nurse should remove the restraints one at a time for a client who is violent or noncompliant. Restraint prescriptions can only be written for a 24 hr period and cannot be a PRN prescription. The nurse should ensure the restraints are removed and ROM exercises are performed every 2 hours, and the nurse should not tie the restraints to the side rails because this can injure the client if the rails are lowered.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes her hands held higher than her elbows [so water and soapsuds can drain away from the clean area toward the dirty area]. 15 strokes each, using fiction and a brush, and washing the hands then elbows first.

A nurse is witnessing a client sign an informed consent form for surgery. What describes what the nurse is affirming this action? The client fully understands the provider's explanation of this procedure. The client has been informed about risks/benefits of procedure The nurse witnessed provider's explanation of procedure The signature on pre-op consent form is the client's

The signature on the pre-op consent form is the client's

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

The signature on the preoperative consent form is the client's. It is the provider's job to inform the client about the procedure [explain it] and explain the risks and benefits. The nurse does not need to witness the provider's explanation of the procedure.

33. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot. Rationale: The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.

C

To prevent post-op complications, nurse assists pt with coughing & deep breathing exercises. This is best accomplished by implementing which of the following? A. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals B. Forceful coughing as many times as tolerated C. Huff coughing ever 2 hours or as needed D. Diaphragmatic and pursed-lip breathing 5-10 times, four times a day

Promoting oxygenation

Try to maintain normal respirations for pt: -Positioning to allow maximum chest expansion (raise head of bed) -Encourage or provide frequent change in position -Encourage ambulation -Implement measure to promote comfort

Stridor

Upper airway -May indicate epiglottis laryngospasm

When ambulating a frail, older adult, the nurse should?

Use a transfer belt if the client is unsteady

Oxygenation

Use humidifying devices for flows >2L -Handle and store cylinders with caution -Place away from traffic and heaters

Controlled coughing

Used after bronchodialater treatment. inhale deeply and hold breath for a few seconds then cough twice 1 to loosen secretions 2 to expectorate secretions

A nurse observes an AP preparing to obtain BP with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

Using a cuff that is too small will result in an inaccurately high reading- Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. The width of the cuff bladder should be 40 percent of the circumference of the client's arm. Although the BP reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading.

Nurse observes another staff member using a regular size BP cuff for a client who is obese. Which explanation should she give? Reading will be inaudible if cuff is too small Width of cuff bladder should be 75% of circumference of arm As long as cuff will circle arm, reading is accurate Using cuff that is too small results in inaccurately high reading

Using cuff that is too small results in inaccurately high reading

Nurse reviews CDC immunization for parents of adolescent. What should nurse discuss?

Varicella, HPPV, seasonal influenza

Review CDC immunization for parents of 2 preschoolers. Recommendations?

Varicella, Polio, seasonal influenza

26. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal Rationale: According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels.

A client is hospitalized for an infection of a surgical wound abdominal surgery. To promoting healing and fight wound infection the nurse plans to arrange to increase the client's intake of

Vit C & Zinc

25. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3 Rationale: This finding is above the expected reference range and is an indication of infection.

After assisting a newly admitted patient in removing hoes and outerware, you notice what appears to be soil or grime on your hands. You?

Wash your hands with soap and water The Centers for Disease Control and Prevention recommends washing with soap and water whenever hands are visibly dirty. In this case, it is the combination of friction, running water, and the properties of soap that remove the soil form the hands.

6. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes Rationale: Washing dishes requires a low level of activity and is appropriate for this client.

Client is being discharged home with O2 Therapy via Nasal Cannula. Which instruction should the nurse give the client/family?

Wear clothing to avoid static electricity.

28. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity. Rationale: The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

A nurse is performing eye irrigation for a client who has been exposed to smoke and ash. Which nursing action should receive the highest priority during the irrigation?

Wearing gloves during the procedure

The nurse is caring for and adult with fluid volume excess. When weighing the client the nurse should

Weigh the client on arising

A nurse is caring for an an older adult client who becomes agitated when the nurse requests that the dentures must be removed prior to surgery. Which response should the nurse make? It's for your safety- dentures can slip and block your airway during surgery. You wouldn't want your teeth to be broken or lost during surgery, would you? The anesthesiologist requires everyone to remove their dentures. What worries you about being without your teeth?

What worries you about being without your teeth?

49. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support. Rationale: The AP should spread his feet apart because a wide base of support increases stability.

crackles

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiration as

Inset earpieces at an angle toward your nose.

When using and maintaining your stethoscope, it is important to

identified a minty scent.

While examining your patients head and face, you determine that cranial nerve 1 is intact when the patient follows your...

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line.

While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following is a normal sounds?

Balance

While performing a head to toe assessment, you perform the Romberg test. You do this to test the patients

Rebound tenderness

While performing an abdominal assessment, you place your fingertips over the patients painful area and gradually increase the pressure. Patient reports increased pain on release of pressure, you document that your patient has positive

Surgical nurse demonstrates the proper hand washing technique by scrubbing

With her hands held higher than her elbows

Client tells nurse, "I'd better off dead because I'm totally worthless." Which is the appropriate nursing response?

You have been feeling very sad and alone for some time now.

a nurse is caring for a group of medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?

a client is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively

a nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

a client who has asthma

a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension?

a client who smokes one pack of cigarettes each day

a nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

a nurse asks a nurse from another unit to assist with documentation for a client

complicated grief

a person has a prolonged or significantly difficult time moving forward after a loss

sufactant

a phospholipid that reduces the surface tension in the alveoli and prevents them from collapsing

Vibration

a series of vigorous quiverings produced by hands that are placed flat against the pts chest wall. -Used after percussion to increase turbulence of exhaled air to loosen thick secretions -Done alternately with percussion -Vibrate (shake) flat hands (using mostly heel of hand) against chest wall moving them downward while pt exhales (5 exhalations) -Encourage pt to cough and deep breathe

A nurse is caring for a client who is terminal diagnosis and whose health is declining. The client request information about advance directives. Which of the following responses should the nurse make? a) "We can talk about advanced directive's and I can also give you some brochures about them" B) "You should set up a time to talk with your provider about that" C) "let's discuss how you're feeling today and will see the planning for when you're feeling better" D) "why do you want to discuss this without your partner here to plan this with you?"

a) "We can talk about advanced directive's and I can also give you some brochures about them"

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? a) Albumin level of 3g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20

a) Albumin level of 3g/dL

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply) a) Check the cord routinely for frays or tearing b) Keep the unit at least 4 feet away from a gas stove c) Consider purchasing a generator for power backup d) Observe for signs of hypoxia e) Select synthetic clothing and bedding

a) Check the cord routinely for frays or tearing c) Consider purchasing a generator for power backup d) Observe for signs of hypoxia

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? a) Talk directly to the client, instead of the interpreter, when speaking. b) Use a family member as the client's interpreter. c) Make sure that the interpreter has a college degree. d) Avoid asking the client personal questions through the interpreter.

a) Talk directly to the client, instead of the interpreter, when speaking.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a) Wrap blankets around all four sides of the bed. b) Apply restraints during seizure activity. c) Place the client in a supine position during seizure activity. d) Have a tongue depressor at the client's bedside.

a) Wrap blankets around all four sides of the bed.

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? a. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask b. A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula c. a client who has an old tracheostomy and is reciting 40% humidified oxygen via tracheostomy collar d. a client who has COPD and is receiving oxygen at 2 L/ min via nasal cannula

a. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? a. Remove the sleeve of the gown from the arm without the IV line b. Slow the infusion using the roller clamp c. Disconnect the IV line from the pump d. Bring the IV-solution and tubing from the outside to the end side of the sleeve of the gown

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

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? a. Renew the prescription for the use of restraints within 24 hours b. Secure the restraints with the buckle side next the client's skin c. Ensure 4 fingers can be inserted under the secured restraint d. Remove the restraint every 3 hr.

a. Renew the prescription for the use of restraints within 24 hours

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing. b. Allow 30 seconds between suctioning passes c. Hyperventilate the client with 50% oxygen for 30 seconds d. Perform a maximum of 4 passes with the suction catheter

a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. which of the following actions should the nurse take first? a. start chest compressions b. Provide breaths with a manual resuscitation bag. c. Administer oxygen d. establish an airway

a. start chest compressions

what is virulence?

ability of pathogen to produce disease

Before doing CPR RN must confirm which assessment before beginning

absence of pulse

Pharmacokinetics (4 components)

absorption, distribution, metabolism, excretion

alarm

activate the facility alarm, then report details of fire following protocols

RN is planning ROM exercises for client. RN understands that active ROM is performed before passive ROM because....

active ROM is used to determine limitation of movement

active natural immunity active artificial immunity passive natural immunity passive artificial immunity

active natural: body produces antibodies in response to exposure to live pathogen active artificial: body produces antibodies in response to vaccine passive natural: antibodies are passed from mom to her baby through placenta or breastmilk passive artificial: immunoglobulins are administered to an individual after they have been exposed to a pathogen

NG/G tube med admin

administer each med separately. dissolve tablets in 15-30 ml sterile water FLUSH TUBE BEFORE AND AFTER EACH MED WITH 15-30 ML WATER (INCLUDING AFTER ALL MEDS ARE GIVEN)

Nurse will be administering several meds to pt. who has enteral feedings via bore NG tube. Nurse administers meds correctly by...

administering meds via large bulb syringe (WRONG) **Infusing each medication by gravity and flushing with water before and after instillation.

mother delays toilet training b/c of teaching from nurse

affective learning

metabolism is affected by:

age: infants and elderly have decreased metabolism, resulting in higher risk for toxicity first pass effect: some meds are inactivated on their first pass through the liver, and must be administered through the parenteral route. some meds can affect the metabolism of other meds poor nutrition can decrease metabolism

ABCDE guidelines include?

airways: establish an airway breathing: once you have an airway, determine effectiveness of breathing Circulation: after ventilation assess circulation disability: determine pt's level of consciousness exposure: determine pt's exposure to adverse elements (heat or cold, etc)

RN takes vitals & notes BP elevation & heart rate. RN should recognize this response as which part of general adaption syndrome?

alarm reaction

3 stages of general adaptation syndrome

alarm-resistance(fight flight), resistance(normalize), exhaustion(prolonged)

LOC

alert lethargic- falls asleep easily obtunded- response to light shaking, but confused and slow to response stuporous- barely response to painful stimuli, confused and slow to repond- rub sternum comatose

Acute care to rehab transfer

alert & oriented has shellfish allergy request morphine every 4 hr

levels of consciousness

alert: patient is responsive, opens eyes spontaneously, and answers questions appropriately lethargic: patient can open eyes, respond to questions, but falls asleep easily obtunded: patient responds to light shaking, but is confused and slow to respond stuporous: patient barely responds to painful stimuli (rubbing sternum) comatose: patient is unresponsive. abnormal posturing may be present

nurse caring for a pt who is heavily draining wound that continues to show evidence of bleeding which dressing should the nurse select to help promote hemostasis

alginate

ear assessment

alignment: top of auricles should be at the same height as inner canthus of eye otoscope: insert 1-1.5 in into ear canal. DO NOT TOUCH ear canal tympanic membrane:intact, pearly gray light reflex: visible at 5 o clock right ear. 7 o clock in the left hour in a cone shape cerumen: expected findings in ears

positioning

allow maximum chest expansion, raise head of bed (semi or high fowlers), help secretions not to pool and promote infections,

Alarm Reaction Stage

also the flight response (the body reacts to the stressor) heart rate and BP increase cortisol is released, boost of adrenaline

Role ______ occurs when a person is unclear about the expectations of his role in a given situation.

ambiguity

a nurse is preparing to delegate client care tasks to an assistive personnel. which of the following tasks should the nurse delegate?

ambulating a client who is postoperative

Which should nurse assess before administering meds through NG tube?

amount of residual volume left in stomach

half life

amount of time it takes for med to be reduced by 50 % in the body meds with short half-life leaves the body quickly meds with long half-life increases risk of toxicity

How to assess drainage?

amount, integrity of skin around it, color, consistency, odor.

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

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

what are bioterrorism agents?

anthrax, variola, C. botulism, yersinia pestis.

increased RR

anxiety, smoking, illnesses, anemia, high altitude

a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

apply an ankle-foot orthotic device to the client's feet

Postop client's knee dressing becomes saturated with blood after transfer to clinical unit. Appropriate nursing action is to:

apply direct pressure to the operative site

a nurse is caring for a pt who is admitted w/ multiple wounds sustained in a motor vehicle crash understanding the pts specific needs during this initial stage of healing the nurse should incorporate which into pts care to prevent a prolongation of this phase

apply oxygen @ 2 L / min via nasal cannula

Antiembolics, such as low-dose subq heparin,

are frequently given pre & postop to reduce risk of thrombosis formation postoperatively

H2 receptor antagonists, such as cimetidine & ranitidine,

are often prescribed preop to reduce the risk of aspiration by increasing gastric pH & decreasing gastric volume.

Decorticate

arms flexed and internally rotated, legs extended and rotated inward

a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate

intentional tort:

assault: nurse threatens pt battery: nurse hits pt, or gives med against pt's will false imprisonment: nurse inappropriately restrains a pt or administers a chemical restraint such as a sedative

provider

assesses, diagnoses and treats illnesses includes: doctors, advance practice nurses (NP), and PAs

what is a primary survey?

assessment in 60 seconds or less to determine life-threatening conditions, done with standard precautions on (gloves, gown, mask,eye protection, shoe covers), ABCDE guidelines

pt education

assessment: identify patient needs, learning style, ability, and available resources planning: develop mutually agreeable goals/outcomes implementation: do not use medical jargon. make sure materials are at a 6 th grade reading level or below eval: ask pt to explain teaching in their own words, or have them do a return demonstration for psychomotor learning

speech language pathologist

assist with patient issues related to speech, language, and SWALLOWING

when should pts start having mammograms ?

at age of 40

To auscultate a patient's apical pulse accurately, you position the bell or the diaphragm on your stethoscope over the point of maximal impusel, which is located

at the fifth intercostal space at the left midclavicular line -To locate the point of maximal impulse, first located the angle of Louis - bony prominence just below the suprasternal notch. Slide you fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.

what does the s4 heart sound indicate?

atrial contraction can happen in older and athletic adults/children use bell to find

a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

auscultate lung sounds

injury prevention for toddlers and infants

avoid foods that can cause choking place infants on back to sleep do not place anything in crib w/ baby make sure crib slats are <=2 3/8 inches apart keep plastic bags, houseplants, cleansing agents out of reach lock up meds use rear facing car seat until2 use carseats with 5-point harness, place in back seat turn pot handles away from front of stove close bathroom doors, keep toilet lids down

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a) Insert the suction catheter when the client is swallowing b) Apply intermittent suction when withdrawing the catheter c) Place the catheter in a location that is clean and dry for later use d) Hold the suction catheter with her clean, non-dominant hand.

b) Apply intermittent suction when withdrawing the catheter

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? a) Turn the client every 4 hours. b) Elevate the head of the client's bed. c) Hold oral care. d) Increase the room's temperature.

b) Elevate the head of the client's bed.

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? a) Remove the outer cannula cautiously for routine cleaning b) Use tracheostomy covers when outdoors c) Use sterile technique when performing tracheostomy care at home d) Cleanse irritated skin with full-strength hydrogen peroxide

b) Use tracheostomy covers when outdoors

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? a) Have the client wear a mask when receiving visitors. b) Wash her hands before and after contact with the client. c) Assign the client to a room with negative-pressure airflow exchange. d) Instruct all visitors to limit their time with the client.

b) Wash her hands before and after contact with the client.

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? a. "Lunch trays should be here within the hour" b. "I am going to listen to your abdomen" c. "I'll get you some water to drink" d. "I would wait a bit, or you could feel sick."

b. "I am going to listen to your abdomen" A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should osculate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? a. Exhale slowly to reach goal volume b. Hold breath for 5 seconds after goal volume is reached c. Continue to deep breathe between each cycle. d. Limit repeat pattern ob breathing to 5 breaths

b. Hold breath for 5 seconds after goal volume is reached The nurse should instruct the client to hold her breath for 3-5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia

A nurse is chasing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? a. Place the soiled lines on the chair while making the bed. b. Hold the linens away from the body and clothing c. Place the lines on the floor until able to place it in a linen bag. d. Shake the clean linens to unfold

b. Hold the linens away from the body and clothing

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular acciedent Which of the following actions should the nurse take when assisting the client at mealtime? a. Encourage the client to drink fluid before swallowing food. b. Offer the client tart or sour foods first c. Tilt the client's head backward when swallowing d. Turn on the television

b. Offer the client tart or sour foods first

BLS stands for

basic life support- main part of CPR

active artificial immunity

body produces antibodies in response to vaccine

calcium function in the body

bone/teeth formation, nerve and muscle function, clotting

serosanguineous drainage

both serum and blood, watery blood streaked or tinged pink color

changes with age

breasts: more pendulous, atrophy of glands, smaller and possibly inverted nipples chest/lungs: barrel chest (AP transverse diameter), decreased alveoli, kyphosis (increased curvature of thoracic spine) cardiovascular: increased SBP, blood vessels thicken/harden, increased pulse pressure abdomen: increased adipose tissue, decreased secretions (saliva, gastric secretions), decreased bowel motility

where are the bronchial, vesicular, and bronchovesicular regions of the lungs

bronchial is around the neck, bronchovesicular is on the sternum area, and vesicular is where the lungs are located

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident? a) "Incident report completed" b) "Client climbed over the bedrails" c) "Client found lying on floor" d) "Client was trying to get out of bed"

c) "Client found lying on floor"

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? a) Urine has an unusual odor b) Urine specific gravity is 1.035 c) Bladder scan shows 525 mL of urine d) Urine is positive for ketones

c) Bladder scan shows 525 mL of urine

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? a) Reduce dietary sodium b) Administer a loop diuretic c) Evaluate electrolytes d) Restrict intake of oral fluids

c) Evaluate electrolytes

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

c) Make sure two fingers can fit under the sleeves

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? a) The client is receiving formula at room temperature. b) The feedings infuse at a slow, continuous drip over 8 hours each night. c) The family member washes out the feeding bag with warm water once every 24 hours. d) The family member flushes the tubing with water before and after giving medications.

c) The family member washes out the feeding bag with warm water once every 24 hours.

A nurse is assessing a client who has an onset of sever back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? a. "Does the medication you're taking relieve the pain?" b. "Can you point to where the pain is the worst?" c. "What do you think caused the onset of your pain?" d. "Changing positions makes your pain worse, right?"

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

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? a . Place an oxygen mask on the client b. check the client's pulse c. Determine whether the client is able to breather. d. Wrap arms around the client from behind

c. Determine whether the client is able to breather.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? a. Maintain suction while removing the NG tube b. Install 100 mL of air into the NG tube before removal c. Pinch the NG tube while removing the tube d. Instruct the client to breathe in and out during the removal of the NG tube

c. Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? a. Redness at the IV catheter entry site b. A palpable cord is felt along the vein used for the infusion c. Taut skin around the IV catheter site that is cool to the touch d. Bleeding at the IV insertion site

c. Taut skin around the IV catheter site that is cool to the touch

what to do in the case of a dehiscence or an evisceration ?

call for help, stay with pt, cover the wound or any protruding organs with sterile towels or dressing soaked with sterile normal saline solution, DONT RE-INSERT THE ORGANS OR APPLY PRESSURE! watch for signs of shock, keep pt NPO in preparation for surgery. * Have pt supine with hips and knees bent.

Client LOC x 3, dec fall risk

call light w/in reach nonskid footwear complete fall-risk assess

diarrhea

can cause dehydration, fluid/electrolyte imbalances (including metabolic acidosis) skin breakdown around anus symptoms of dehydration: increased HR, decreased BP, poor skin turgor, elevated temp, dry mucous membrane apply moisture barrier (zinc oxide) around anus

skin assessment:

cap refill: should be less than 2 seconds skin turgor: lift skin on sternum or forearm. Tenting indicates dehydration and/or aging. edema: compress the skin. for 5 seconds over bony prominence or lower extremity 1+ = 2mm (scant edema, quick rebound) 2+ = 4mm (mild edema, 15 sec. rebound) 3+ = 6mm (moderate edema, 30 sec. rebound) 4+ = 8 mm (severe edema, > 30 sec. rebound)

chain of infection

causative agent (toxin, bact) reservoir (human, soil) portal of exit (blood, resp tract) mode of transmission (contact, droplet) portal of entry (susceptible host)

valvsalva maneuver

cause by bearing down or straining advise pt not to bear down while having a bowel movement can result in bradycardia, hypotension, syncope

Hyponatremia

cause: GI losses, diuretics, skin loses, SIADH, edema, hyperglycemia symptoms: tachycardia, hypotension, confusion (common in elderly), fatigue, n/v, headache

herpes zoster

caused by reactivation of varicella zoster virus (viruses that cause chickenpox) risk factors: compromised immune system, stress, fatigue, poor nutrition symptoms: painful, unilateral rash that runs horizontally along a dermatome rash that is vesicular, pustular, or crusting low-grade fever paresthesia

Hypomagnesemia

causes: GI loss, diuretics, malnutrition, alcohol abuse symptoms: dysrhythmias, tachycardia, hypertension, tremors, seizures, increased DTRs

Hypokalemia

causes: GI loss, diuretics, skin loss, metabolic alkalosis symptoms: dysrhythmias, muscle weakness, cramps, constipation,/ileus, hypotension

Hypocalcemia

causes: diarrhea, vit D deficiency, hypoparathyroidism symptoms: + chvosteks , + Trousseas sign, muscle spasms, numbness/tingling in lips/fingers, GI upset

Hypercalcemia

causes: hyperparathyroidism, long-term steroid use, bone cancer symptoms: constipation, decreased DTRs, kidney stones, lethargy

Hypermagnesemia

causes: kidney disease, laxatives containing mag. symptoms: hypotension, muscle weakness, lethargy, respiratory and cardiac arrest

Hyperkalemia

causes: uncontrolled diabetes (DKA), metabolic acidosis, kidney failure, salt substitutes symptoms: dysrhythmias, muscle weakness, numbness/tingling, diarrhea, confusion

hypernatremia

causes: water deprivation, excess sodium intake, kidney failure, Cushing's syndrome symptom: tachycardia, muscle twitching/weakness, GI upset, edema

carbon dioxide

cellular metabolism produces

A nurse is caring for patient with stage IV sacral pressure ulcer fro which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for this patient?

changing dressing using the wet-to-dry method

nurse caring for pt w/ stage wound 4 sacral pressure ulcer for which the provider has prescribed mechanical debridement. which should nurse use

changing dressing using the wet-to-dry method

if a dysrhythmia exists what should you do?

check for a pulse deficit

lungs with aging?

chest shape changes barrel chest like, decrease in capacity, cough reflex diminishes, cilia become ineffective at removing particles, alveoli diminish, kyphosis: curvature of spine reduces lung capacity/expansion.

idiopathic pain

chronic pain of unknown orgin often associated with depression

triage

class 1 (red): immediate threat to life. breathing issues, hemorrhagic wound, major burns class 2 (yellow): major injury that requires treatment (bone fracture) class 3 (green tag): minor injury does not require immediate treatment (abrasions, cuts, sprains) class 4 (black): expected and allowed to die (penetrating head wound, chest crush injury)

three classes of fires?

class a: paper, wood, rags, etc trash fires class b: flammable liquids or gas fire class c: electrical fire

wound cleaning

clean from lease to most contaminated. (clean incision, then surrounding skin) ******irrigation: use 30-60 ml syringe, 5-8 psi of pressure******

wound cleaning

clean from least to most contaminated (clean incision, then surrounding skin)

Foley catheter care

clean insertion site with soap and water 3x/day and after BMs keep collection bag below level of bladder make sure tubing is not kinked (and no dependent loops)

a nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take?

cleanse the wound from the center outward

a nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident?

client found lying on floor

mass casualty event, who can be discharged

client scheduled for prostate resection 24 post-op after mastectomy

The nurse knows that to achieve success in this teaching program, the information about the client that is most important is thie

client's goal concerning his ability to be self-sufficient

factors that increase the risk for UTIs

close proximity to urethral maetus and anus, frequent sex, menopause/decreasing estrogen uncircumcised males, use of indwelling catheters, cleansing from back to front, providing regular catheter care.

Bleeding effects from meds

coffee-ground emesis, tarry stools, bruising, petechiae, bleeding gums, oozing blood from IV site

adverse effects of meds: bleeding

coffee-ground emesis, tarry stools, bruising, petechiae, bleeding gums, oozing blood from IV site

sputum samples

collect early in morning, ideally through coughing (vs. suctioning)

timed urine specimen

collect for 24 hrs, discard first voiding, collect all others and refrigerate them,

living will

communicates patient's wishes regarding medical treatment if patient becomes incapacitated.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

compare prescriptions with medications the client received while are the facility

therapeutic index

compares the minimum effective concentration (MEC- amount at which drug is effective) to the level at which the drug is toxic meds with a high TI are safer, no need to monitor blood levels meds with low TI require close monitoring of blood levels (peak and trough levels) trough levels should be taken right before next med dose

Following ER splenectomy, client is admitted to unit from PACU. Client reports abd pain and client's parent are asking to see child. RN's first action is:

complete a physical assessment including postop vitals

risk factors for infections

compromised immunity chronic/acute disease poor personal and hand hygiene crowded living space IV drug use unprotected sex poor sanitation

Normal curvature of spine

concave cervical spine, convex thoracic spine, concave lumbar spine , convex sacral spine

congestive heart failure, and hypovlemia

conditions that decrease cardiac output, ___________ and _________, affect tissue oxygenation and also the body's ability to compensate for hypoxemia

late stage signs of hypoxemia?

confusion, stupor, cyanotic skin, mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysrhythmias.

Before giving preop med to a client being prepared for surgery, the nurse must make sure that the

consent form has been signed

A new RN notes prescribe has prescribed med with which RN is unfamiliar with. The RN should:

consult the medication reference book available on the unit.

contain

contain fire by closing doors/windows & turning off O2 or electrical devices *pt on life suport should be put onto a respiratory bag

a nurse is caring for pt who has m s & has a chronic nonhealing wound . Nurse knows which med delays wound healing

corticosteroids suppress immune system and delay wound healing

Nurse precepting new RN who is about to perform tracheotomy care. She should intervene if new RN brings

cotton balls

rhonci

course sounds during inspitation or expiration, from fluid, mucous, or trouble clearing airway

Burns

cover pt, NPO status elevate their extremities preform head to toe, estimate area of affectedness administer fluids/tetanus toxoid.

Bold pressure

cuff width should be 40 % of arm circumference bladder should surround 80 % of arm circumference cuff too large: false low reading cuff too small: false high reading key points when taking bp: do not take in arm with IV/infusion running Do not take bp on side of mastectomy, AV shunt, fistula to estimate SBP using auscultatory method: palpate radial pulse and imitate cuff until pulse disappears, inflate cuff another 30 mmhm, release pressure and note when pulse is palpable again

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? a) "This type of hearing aid does not allow for fine tuning of volume." b) "I shouldn't have trouble keeping the hearing aid in place during exercise." c) "I expect to hear a whistling sound when I first insert the hearing aid." d) "I will be sure to remove my hearing aid before taking a shower."

d) "I will be sure to remove my hearing aid before taking a shower."

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client? a) "Rashes are very common, especially if you have dry skin. Did it go away on its own?" b) Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotics." c) "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash." d) "We need to document the exact medication you were taking because you might be allergic to it."

d) "We need to document the exact medication you were taking because you might be allergic to it."

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? a) Encourage the client to relax and take deep breaths during the dressing change b) Educate the client about the importance of the dressing change to prevent infection c) Assist the client to a comfortable position for the dressing change d) Administer pain medication 45 minutes before changing the client's dressing

d) Administer pain medication 45 minutes before changing the client's dressing

A nurse receives a report about a client who has 0/9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following action should the nurse take first? a) Reposition the client b) Document the client's IV intake in the medical record c) Request a new IV fluid prescription d) Check the IV tubing for obstruction

d) Check the IV tubing for obstruction

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? a) Oat cereal b) Refried beans c) Peanut butter d) Cheddar cheese

d) Cheddar cheese

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a) Seal unused hospital medications in a plastic bag. b) Evaluate the client's ability to self-administer medications. c) Report an identified discrepancy to The Joint Commission. d) Compare prescriptions with medications the client received during hospitalization.

d) Compare prescriptions with medications the client received during hospitalization.

A nurse is caring for a client who has major fecal incontinece and reports irritation in the perianal area. Which of the following actions should the nurse take first? a. Apply a fecal collection system b. Apply a barrier cream c. Cleanse and dry the area d. Check the client's perineum

d. Check the client's perineum

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? a. Withdraw the specimen from the drainage bag. b. Cleanse the collection port with soap and water c. Place the specimen in a clean specimen cup d. Clamp the tubing below the collection port

d. Clamp the tubing below the collection port Should do this so fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup

A nurse is caring for a client who had a mastectomy and has self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? a. Irrigate the tubing with sterile normal water once each shift b. Cleanse the opening with soap and water after emptying c. Maintain the tubing above the level of the surgical incision d. Collapse the device of air after emptying

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

A nurse is applying antiembolitit stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? a. Roll the stockings partially down if too long. b. Remove the stockings once per day c. Bunch and pull the stockings half way up the calf. d. Turn the stocking inside out up to the heel before applying

d. Turn the stocking inside out up to the heel before applying

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? a. tenderness when touched b. Pink, shiny tissue with a granular appearance c. Serosanguineous drainage d. a halo of erythema on the surrounding skin

d. a halo of erythema on the surrounding skin

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? a. Speak directly into the client's impaired ear. b. Exaggerate lip movements c. speak loudly d. face the client while speaking

d. face the client while speaking

what does immobility do to the cardiac system

decreases cardiac output which leads to poor cardiac effectiveness and results in increased cardiac workload.

low flow systems

deliver oxygen via small-bore tubing. include: Nasal cannulas Face masks Oxygen tents Transtracheal catheters

stages of grief

denial, anger, bargaining, depression, acceptance

sexually active 19 yr old. 1st check up

determine pt's risk factors

when a pt is bleeding, you should?

determine source of bleeding, apply direct pressure, do not remove object if internal bleeding may need to administer fluid/blood replacement/surgery

teaching management of stress incontinence

determine what pt knows about stress incon

continuous positive airway pressure (CPAP)

device used to treat sleep apnea; includes a mask that fits over the sleeper's nose, which pumps air into the person's airways, forcing them to remain open

obstructive airway disease

diaphragmatic and pursed-lip breathing techniques are used for pts with:

patient discharge

diet/activity restrictions detailed instructions for procedures at home (such as wound dressing) list of meds, when to take them, precautions for them signs/symptoms of complications, when to seek medial attention follow-up appointment info names, numbers of providers and community resources

pulse deficit

difference between apical pulse rate and radial pulse rate

pulse deficit

difference between the apical and radial pulse rates

Dyspnea

difficulty breathing or the feeling of being SOB

Dysphagia

difficulty swallowing

24 hour urine collection

discard first void, collect all urine for 24 hours do not allow contamination with stool keep urine on ice

sterile field

do not cough, sneeze, or talk over field 1 in edge of field is NOT sterile; discard any item that comes in contact with this area below waist, and above chest is contaminated add objects to sterile field at least 6 " above the field never turn your back, or reach across the field any sterile item that comes in contact with moisture, is considered non sterile

correct use of walker

do not use to stand up flex elbows 20-30 degrees advance 12 inches, weak first, then strong leg forward

patient admission

document patients advance directive status vital signs, ht, wt, allergies head 2 toe assessment, health history spirit and cultural considerations assess for swallowing issues prior to allowing pt to eat or drink safety assessment. fall precautions if needed inventory, lock values in safe med rec: compare home meds w/ providers prescriptions discharge planning starts on admission!!!!

Beneficence

doing good (what's best for pt)

suctioning procedure

don PPE, assist into high fowlers, obtain baseline for vitals, if O2 down use oxygen loosely, yankauer, 10-15 seconds to avoid hypoxemia, limit to 2-3 tries, apply only while withdrawing, give one min of rest between each go.

oxygen in home safely

don't use nail polish no smoking sign on door fire extinguisher in home

when applying heat?

dont apply to abdomen, careful over bony prominences, not on immobile pts avoid over pacemakers, prosthetic joints

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

droplet

neuropathic pain

due to damage to nerves in body (phantom limb pain, diabetic neuropathy) symptoms: shooting, burning, "pins & needles" treat with antidepressants, anticonvulsants, muscle relaxers

Nociceptive pain

due to tissue damage or inflammation symptoms: aching, throbbing, localized treat with opioid or non-opioid analgesics -somatic: bones, joints, muscles, connective tissues -visceral: internal organs (may cause referred pain) -cutaneous: skin or subcutaneous tissue

DPOA

durable power of attorney patient designates health care proxy to make medical decisions for them if they become incapacitated.

adverse effects of meds: extrapyramidal symptoms

dystonia, Parkinson's symptoms, akathisia, tardive dyskinesia

Extrapyramidal symptoms

dystonia, akathisia, parkinsonism, tardive dyskinesia

injury prevention for adolescence

educate teens on risks associated with smoking, drugs, alcohol, and unprotected sex warn against distracted or impaired driving reinforce need for seatbelts monitor for mental health issues (depression, anxiety)

what usually causes fires in health care settings?

electrical problems or anesthetic equipment unauthorized smoking

nursing care of eternal feeding tubes

elevate HOB to > 30 degrees during feeding and 30-60 minutes after feeding cover and label unused formula with patient information, refrigerate for up to 24 hrs fill feeding bags with only 4 hours worth of formula to prevent bacterial contamination slowly increase volume/rate to desired level. wean off of enteral feeding as oral consumption increases

discontinuing IVs

elevate arm and hold pressure for 2-3 mins (longer if pt is on anticoags) make sure catheter tip is intact

Discontinuing IVs:

elevate arm and hold pressure for 2-3 minutes (longer if pt is on anticoagulants) make sure catheter tip is intact

papule

elevated solid lesion, <1 cm (mole, nevus)

plaque

elevated solid lesion, > 1 cm (psoriasis)

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client

smoke from under door

evacuate the clients

A nurse is admitting a client with decreased circulation in left leg. Which action should nurse take first? Evaluate pedal pulses Obtain medical history measure vitals assess for leg pain

evaluate pedal pulses

how often should pts be coughing/deep breathing

every 1-2 hrs

how often should skin be assessed for immobile patients

every 2 hr

pap smear

every 3 years after 21

How often do you measure gastric residual with NG tubes?

every 4-6 hours, return residual to stomach, hold feeding for residual amount over hospital policy (500ml)

how often should hot or cold packs be assessed?

every 5-10 minutes: check for redness/pallor pain or burning numbness shivering decreased sensation cyanosis

lordosis

excess curvature of lumbar spine (common in pregnancy and toddlers)

kyphosis

excessive curvature in thoracic spine (common in elderly)

Ventilation

exchange of 02 and CO2 in the lungs

Perfusion

exchange of O2 and CO2 between the RBCs and the body tissues

Diffusion

exchange of O2 and CO2 between the alveoli and RBCs ( in the bloodstream)

situational loss

experienced as a result of an unpredictable event

Admission procedure:

explain roles of care staff start discharge planning provide info about advance directives intro pt to roommate

changes in older adults

eyes: decreased vision, yellowing of lens, issues w/ glare and darkness ears: hearing loss, thickening of tympanic membrane mouth: decreased sense of taste, gum disease, tooth loss, decreased salivation, pale gums voice: increased vocal pitch nose: decreased sense of smell

cardiac output number of erythrocytes and blood hematocrit exercise

factors that affect the rate of oxygen trransport from thelungs to the tissue

To evaluate stereognosis, RN should ask client to close eyes & identify

familiar object she places in his hand

ethical dilemma

family conflicted about start feeding tube on terminally ill dad

prevention of UTIs include?

females: wipe front to back Cath care uncircumcised male: clean under foreskin drink 2-3 L of fluid daily cranberry juice decreases risk of UTIs

play activities for toddlers

filling & emptying containers playing w/ blocks looking at books

nodule

firm, deep, 1-2 cm (wart)

Macule

flat area of discoloration, < 1 cm (freckle)

patch

flat area of discoloration, > 1cm (birthmark)

expected intake vs. output

fluid intake should approx. equal urine output

if you percuss a patients chest and hear dullness what could be wrong?

fluid is in the lungs could indicate pneumonia or a tumor

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take?

flush the tube with 15 mL of sterile water

secondary prevention

focuses on early detection of disease, limiting severity of disease. ex: screenings, control of outbreaks

affective learning

focuses on feelings, ideas, beliefs, and values

Psychomotor learning

focuses on physical skills (coordination, movement, manipulation)

when should a rear facing car seat be used?

for children until 2 yrs old or until they exceed the height/weight limits

hospice care

for patients with terminal illness, not expected to live more than 6 months, focus on symptom relief, NOT curing disease

Heimlich chest drain valve

for pts with common pleural effusions, drain fluid off of chest without having to tap the lung everytime

Huff coughing

forced expiratory technique, may be taught as alternatives for pts who are unable to perform a normal forceful cough -Pt with pulmonary condition (COPD) lean forward exhale through pursed lips and exhale with a "huff" sound in mid-exhalation -helps keep airway open while moving secretions in an out of lungs -inhale by taking rapid short breaths in succession to prevent mucous from moving back into smaller airways -rest and repeat the process

stage 4 pressure ulcer

full thickness loss of tissue with destruction, necrosis, damage to muscle and bone, and supporting structures. May be sinus tracts deep pockets of infection, tunneling, undermining, eschar, slough.

stage 3 pressure ulcer

full thickness loss of tissue, damage or necrosis of sub Q tissue, may extend down to but not thru underlying fascia. Drainage and infection are common

a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take?

gently shake the container of medication prior to administration

Benzodiazepines, such as midazolam & lorazepam,

given to reduce anxiety and sedate the client

breasts with aging?

glandular tissues atrophy, adipose tissue replaces it, softer more pendulous, nipples no longer erect, may invert

bed baths

gloves, wheels locked on bed, wash face first, wash one area at a time, perform perineal care with clean water

foods that affect meds

grapefruit juice (statins) foods high in vitamin K high protein foods (Levodopa) tyramine-rich foods (MAOIs) potassium-rich foods (ACE inhibitors) dairy (interacts with tetracycline)

foods that affect medication

grapefruit juice: affects metabolism of many meds including statins foods high in vitamin K: interferes with effectiveness of warfarin high protein foods: interferes with absorption of levodopa (Parkinson's med) Tyramine rich food: can cause hypertensive crisis in patients taking MAOIs. Smoked meats, cheese, avocados, wine, chocolate, bananas, peanuts potassium-rich food: can cause potassium level to be too high in patients taking ACE inhibitors, or potassium sparing diuretics dairy: interacts with tetracycline, do not take tetracycline within two hours of consuming dairy

foods that can cause choking in infants and toddlers

grapes, raw carrots, hotdogs, celery, peanut butter

removing sutures

grasps knot with forceps cut suture close to skin pull out suture in one piece

pleural friction rub

grating sounds from an inflamed visceral and parietal rubbing against each other during inspiration and expiration

anticipatory grief

grief experienced prior to a loss

standard precautions

hand hygiene (pref. alcohol based antiseptic unless hands are visibly soiled) masks, face shields when splashing of bodily fluids clean gloves worn when touching anything that could contaminate the nurse moisture resistant bag for. soiled linens proper sharps disposal

how to measure chest expansion

hands flat on tenth ribs back side, have pt take a deep breath and see how your thumbs move outwards should be roughly 2 in when pt takes a breath in

how to measure tactile fremitus ?

hands flat on the pts chest, have them say 99 each time you move ur hands to measure the equal symmetric vibrations...should be more pronounced at the top than at the bottom

RN determines that CNA performing hygiene care for PT with indwelling catheter needs future teaching when RN observes CNA

hanging the collection bag at the level of the bladder

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting

have family members wear a gown and gloves when visiting

oral hygiene

have suction ready at side of the bed, remove dentures, brush them with soft brush and denture cleaner, rinse them, store in denture cup with water to keep moist, help reinsert

a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use?

have the client stand with their arms at their sides and their feet together

a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown?

have the client use a trapeze bar when changing position

RN is caring for 5 year old child returning from the surgical suite following exploratory laprotomy & removal of a ruptured appendix. When writing the child's nursing care plan, the nurse lists the priority intervention as

having the child turn, cough, & breathe deeply every 2 hr.

decerebrate:

head arched back, arms and legs extended

pt at risk CV disease

health promo: see benefits of action ID support systems set goals teach stress mgmt strategies

red tissue

health regeneration of tissue

Tachycardia

heart rate greater than 100 bpm causes: fever, exercise, meds, pain, stress, hypovolemia, hyperthyroidism

Bradycardia

heart rate less than 60 bpm causes: meds, athletes, hypothyroidism, hypothermia

Expectorants

help "break up" mucus, making it more liquid and easier to expectorate. make sure pt is maintaining hydration drinking fluid -Guaifenesin

Humidifiers and Nebulizers

help hydrate the membranes and thin secretions by delivering humidity and medications

huff coughing

helps keep airways open and secretions mobilized. is an alternative for pts who are unable to perform a normal forceful cough

occupation therapist

helps patient regain their ability to perform ADLs

low levels of what could affect oxygenation/healing?

hemoglobin (anemia)

linear clusters of crusty fluid filled vesicles

herpes zoster

NG tube insertion

high Fowler's towel across chest water-based lubricant sip water while inserting NG tube withdrawal slightly if patient gag/choke check placement by checking pH of gastri contents, CONFIRM PLACEMENT WITH CHEST XRAY

Weber test

hold fibrating fork on top of patients head, to compare hearing on right vs. left side

when using a cane...?

hold on the uninjured side, keep at least two points on the ground at all times, advance the weaker leg first then the unimpaired leg so the weaker leg goes with the cane.

Rinne test

hold vibrating tuning fork on mastoid bone then in front of the ear canal tests for conductive or sensorineural hearing loss expected: air conduction > bone conduction

moist heat

hot compress, hot soaks, sitz baths

dry heat

hot pack, warming blanket

Distribution

how med gets from bloodstream to site of action affected by: -circulation: issues with perfusion such as peripheral vascular dz or CV dz can inhibit distribution. older adults often have circ issues -permeability at destination site -protein binding: meds need protein (albumin) to travel to site of action. Availability of protein and competition for protein binding sites with other meds can affect distribution

Absorption

how med gets from location of admin to bloodstream route: oral, subQ, IM, sublingual/buccal,IV Absorption with PO meds is slower because med must go through GI tract. Absorption depends on: -solubility of meds -presence of food in stomach -GI pH (older adult higher pH) -form of med (liquid, ER)

a pt who has a full thickness wound continues to experience considerable pain during dressing changes, despite analgesia prior. Which should the use to minimize pain of dressing change?

hydrogel - helps keep moist environment + wont adhere to wound

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

i flushed what i urinated at 7 am and have saved all urine since

a nurse is caring for a client who has recently started using a behind the ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

i will be sure to remove my hearing aid before taking a shower

dry cold

ice bag, collar, glove, pack cooling blanket

social worker

identifies and coordinates community resources and other patient needs necessary for discharge and recovery

During eval

identify if pt outcomes have been met

How should a nurse assess for home safety risks?

identify risk factors (risk assessment tool), nursing hx, physical exam, home hazard appraisal.

bad parenting

if my baby can sit up, he can be safe in a bath tub

after

if pt is on antibiotics give them ________ perform percussion because the airways will be more patent and the antibiotics will have a better chance at getting down deeper into the lugns

before

if pt is on bronchodilators give them _____ perform percussion because we want airways patent before we try to loosen secretions

food poisoning

immuno-compromised pt at risk at risk pt eat pasteurized diary products handling raw and fresh food separately

passive artificial immunity

immunoglobulins are administered to an individual after they have been exposed to a pathogen

2 days postop, PT reports gas pain in the periumbilical area. RN notes distension & revises the client's care plan based on knowledge that postop gas pain develop as a result of

impaired peristalsis of the intestines

key points for administering restraints:

in an emergency, the RN can place a pt in restraints, but must get prescription from doctor asap (within an hour) orders can be written up for up to four hours for adults remove each restraint one at a time every 2 hours-assess skin integrity, neuromuscular checks, provide ROM use least restrictive restraint to correct problem (mittens) quick release knot apply restraints so 2 fingers can fit between restraint and pt

You are measuring a patient's temp. orally. You place the covered probe

in the posterior linguinal pocket lateral to the midline -The heat produced by superficial blood vessels in the right and left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe sideways into the back of the area under the tongue on the left or the right will access this area.

urge incontinence

inability to reach bathroom in time due to overactive detrusor muscle.

Metabolism

inactivation of meds by enzymes. Happens in liver primarily, but also in the kidney's, lungs, and intestines.

improve pulmonary ventilation, counteract the effects o anesthesia or hyperventilation, loosen respiratory secretion, facilitate respiratory gaseous exchange, expand collapsed alveoli

incentive spirometry are used to

lab results for FVD fluid volume deficit

increased Hct increased serum osmolarity increased urine specific gravity (>1.03) hypernatremia (>145 mEq/L)

symptoms of dehydration

increased pulse rate, hypotension, poor skin turgor, elevated temp, dry mucus membranes

Signs of trouble breathing?

increased work breathing, wheezing, coughing, cyanosis, changes in resp rate/rhythm, adventitious breath sounds, restless, irritable, confused.

bladder training programs

increases bladders ability to hold urine and pts ability to suppress urination. should void at scheduled times increase voiding intervals if no incontinence episodes for 3 days 4 hr interval, remind them to hold urine until scheduled toiletting time, keep track of voiding times

Stages of infection

incubation- time from when pathogen enters the body until the first symptom appears prodromal- time from onset of general symptoms (malaise, fatigue) to specific symptoms illness- specific symptoms occur convalescence- symptoms disappear to complete recovery (can take months)

supplemental oxygen

indicated for pts who have hypoxemia due to the reduced ability for diffusion of oxygen through the respiratory membrane, hyperventilation, or substantial loss of lung tissue due to tumors or surgery.

rebound tenderness?

indication of irritaion or inflammation somewhere in the abdom cavity, should apply pressure for 4 seconds then release and observe pts response

contact precautions

infections: impetigo, scabies, MRSA, VRE, CDIFF (and other enteric precautions), RSV, wound infections -private room or with another pt with the same infection gloves and gowns for caregivers and visitors

Skin blanching, edema, and coolness at the IV site indicate ______.

infiltration

Stages of wound healing

inflammatory stage (3-6 days): vasoconstriction, clot formation, hemostasis. phagocytosis of microorganisms proliferative stage (3-24 days): replacement of lost tissue with granulation tissue and collagen, wound contraction, wound resurfacing (with new epithelial cells) maturation stage (1 +years): remodeling and strengthening of collagen tissue

a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice?

initiate an enteral feeding through a gastrostomy tube

When taking a adults patient's temperature rectally, it is important to

insert the probe about an inch and a half into the patient's anus -An insertion depth of 1.5 inches (3.5 cm) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables to measure heat maximally and accurately.

patient teaching: foot care:

inspect feet daily test water temp, using lukewarm water dry feet throughly after bathing apply moisturizer to feet, but NOT between toes wear cotton socks (NO synthetic fabrics) cut nails straight across check shoes for objects that cause injury DO NOT use OTC products, such as products for corns/calluses DO NOT apply heating pads to feet

foot care

inspect feet daily, pay attention to between the toes, lukewarm water, dry feet thoroughly, apply moisturizer, avoid over the counter products, wear clean socks, check for objects, cut nails straight across, apply lotion and powder,

when assessing the abdomen what is the order of steps?

inspect, auscultate, percuss, palpate

how to assess the thorax and lungs?

inspect, palpate, percuss, auscultate

abdominal assessment order

inspection, auscultation, percussion, palpation

stage 1 pressure ulcer

intact skin, nonblanchable redness warmer or cooler than surrounding tissue

palliative care

interventions focus on symptom relief. can be given at the same time as treatments to cure disease, or during end of life

RN caring for PT who is immobilized knows that, without interventions to prevent constipation & fecal impaction, PT is at risk for

intestinal obstruction

what to irrigate a wound with?

isotonic solution or a cleansing agent.

sensorineural hearing loss

issue in inner ear or auditory nerve (CN VIII) causes: ototoxic meds (gentamicin, furosemide, NSAIDs), excess exposure to loud sounds, old age Rinne test: air conduction > bone conduction weber test: lateralizes to unaffected ear

conductive hearing loss

issue in middle ear that blocks sound waves from reaching inner ear. causes: packed cerumen, tympanic membrane damage (r/t middle ear infections), old age (otosclerosis) rinne test: bone conduction > air conduction weber test: lateralize to affected ear

Carbon Monoxide

it binds w/ Hgb in body

what affects does a mastectomy have on the lymph system?

it can cause lymphedema due to the impaired lymph system draining on the affected side

prevention of pressure ulcers?

keep skin clean, dry, intact, provide firm, wrinkle free linens, pressure reducing surfaces, clean skin with mild cleanser, bathe in warm but not hot water, minimal scrubbing, dont use powder or cornstarch reposition every 2 hrs, pressure reducing bed or chair, lift instead of pulling pt up in bed, raise heels off of bed, ambulate as much as possible, shift wt every 15 mins, hydrate, don't massage bony prominences, encourage vitamin A C zinc and copper

orthodox Judaism

kosher kitchens no meat with dairy no pork or shellfish

chronic pain

lasts longer than 6 months does not alter VS causes: fatigue, depression, and interferes with ADLs

otic drops

lay pt on unaffected side pull auricle up and back for adults, down and back for children under 3. hold dropper 1 cm above ear canal. install then gentle pressure on tragus pt should remain on side for 2-3 mins

Otic eye drops

lay pt on unaffected side pull auricle up and back for adults, down and back for children under 3. hold dropper 1 cm above ear canal install drops, apply gentle pressure on tragus pt should remain on side for 2-3 min

where to hear the apical/mitral valve

left midclavicular line at 5th ICS

PMI (apical impulse)

left midclavicular line, at the fifth intercostal space

where to hear the tricuspid valve?

left of sternum, 4th ICS

where to hear the pulmonic valve?

left of the sternum, second ICS

What to assess with a wound?

length, width, depth, undermining, tunneling, tracts, redness or swelling...use clock face with 12 o'clock as the pts head

baby w/ loose stools from first eating veggies/fruits. Nurse asks:

let's make a list of food he's eating? did changes start after 1 particular food? has he been vomiting since starting these new foods?

orthostatic hypotension adverse effect of meds

light headed/ dizziness when standing up (due to decrease in BP). Patient teaching: change positions slowly

adverse effects of meds: orthostatic hypotension

lightheadedness or dizziness when standing up (due to decrease BP) patient teaching: change positions slowly

A nurse is receiving client from PACU who is post-op following abdominal surgery. Which action should nurse take to transfer client from stretcher to bed? Lock wheels of bed and stretcher Instruct client to raise arms above head Elevate stretcher 1 inch above height of bed Log roll client

lock wheels of bed and stretcher

what affects wound healing time?

loss of skin turgor (old people or dehydrated), skin fragility, decrease in peripheral circulation/oxygenation, decrease in collagen, impaired function of immune system.

Secondary intention Healing

loss of tissue, wound edges are widely separated like with pressure ulcers, open burn areas. -longer healing time -increase risk of infection -scarring

what sounds would you expect to hear over to bronchial when auscultating?

loug high pitched , expiration is longer than inspiration over trachea

Carbohydrates

main source of energy makes up 45-65 % of calories provides 4 cal/g of energy glycogen is stored carb energy in the liver and muscle, released in between meals to maintain blood glucose levels

IV care

maintain IV patency by flushing w/ NS every 8-12 hours when pt isnt receiving continuous IV infusion change IV sites according to facility policy (every 72 hours) replace IV tubing according to policy (24-48 hrs) wipe all ports with alcohol or antiseptic before connecting lines or a syringe

a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day

A nurse is planning to insert NG tube. Improper use of NG tube is

maintaining NPO status

perineal care

maintaining skin integrity, provide privacy, maintain professional demeanor, remove any fecal matter, cleanse from front to back, dry thoroughly, retract foreskin to wash tip of penis

potassium function in the body

maintains ICF, nerve function, regulates muscle and heart contractions

sodiums function in the body

maintains fluid balance in body, nerve, and muscle functioning

Nurse pre-op care w/ informed consent

make sure surgeon obtains consent witness client's consent on form

tertiary prevention

maximize recovery after injury /illness ex: rehab, PT/OT, support groups

delegation to LPN

med administration, enteral feedings, urinary Cath insertion, suctioning, tracheostomy care, reinforcement of pt education

agonist

med that activates a receptor in the body ex. morphine is an opioid agonist that activates opioid receptors in the body, causing sedation/analgesia

Antagonist

med that blocks a receptor in the body ex. naloxone is an opioid antagonist that blocks opioid receptors

a nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider?

medication dose

benzodiazepine sedative-hypnotics and antianxiety drugs (e.g. diazepam [valium], lorazepam [ativan], midazolam [versed]), barbiturates (e.g. phenobarbital), and opioids such as morphine

medications that can decrease the rate and depth of rspirations. The most common medication having this effect are

what sounds would you hear auscultating the bronchovesicular area?

medium pitch, equal inspiration an expirations

clean catch

midstream for culture and sensitivity after thorough cleansing of the urethral area, takes sample midstream

A RN caring for preop client administers atropine as prescribed to

minimize oral & respiratory secretions.

S1 (lub)

mitral and tricuspid valves closing

heat stroke

must be identified quick/treated aggressively, S&S: hot, dry skin, hypotension, tachypnea, tachycardia, anxiety, confusion, weird behavior, seizures, coma. treat by rapid cooling, remove clothing, ice packs on axillae, chest, groin, neck cold-water bath,

a nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following?

narrowed arterial lumen

Oxygen delivery

nasal cannula 1-6 L/min, if >4 use humidifier simple mask: 5-8 partial rebreather: 6-10, ensure reservoir bag is 1/3 to 1/2 full on inspiration nonrebreather mask: 10-15, keep reservoir bag 2/3 full, assess valve and flap hourly venturi mask: 4-12; MOST PRECISE aerosol mask/face tent: trauma/burns, high humidification

Oxygen delivery

nasal cannula: 1-6 L/min. use humidification for flow rate >4 L/min simple face mask: 5-8 L/min partial rebreather mask: 6-10 L/min. ensure reservoir bag is 1/3 to 1/2 full on inspiration nonrebreather: 10-15 L/min. keep reservoir bag 2/3 full. assess valve, flap hourly venturi mask: 4-12 L/min. MOST PRECISE O2 DELIVERY aerosol mask/face tent: good for patients with facial trauma or burns; provides high humidification

For which of the following inhalation med. delivery methods is it important for nurse to assess pt's ability to inhale deeply before administering meds?

nasal spray (WRONG) **dry powder inhaler

Unintential Tort

negligence: (forgetting to set bed alarm for a patient who is at risk for falls) malpractice: (med error that harms the pt)

Magnesium's Function in the body

nerve and muscle function, bone formation. Critical for many biochemical reactions in the body.

unstageable pressure ulcer

no determination of stage because of slough or eschar obscuring the wound.

Pt. has been prescribed Flovent HFA inhaler w/ spacer. Pt. questions need for spacer. Correct response?

no spills (WRONG) **suspends the med better and distributes through lung better

nociceptive pain vs neuropathic pain

nociceptive- due to tissue damage or inflammation. aching and throbbing localized. (somatic, visceral, cutaneous) neuropathic- burning, shooting, pins/needles, damage to nerves in body, phantom limb, diabetic neuropathy. treat with antidepressants, anticonvulsants, muscle relaxers

Symptoms of oxygen toxicity

non-productive cough substernal pain nasal congestion n/v fatigue headache sore throat

nonspecific innate immunity vs specific adaptive immunity

nonspecific innate: defense mechanisms (barriers) in the body that respond immediately to all antigens. Barriers include skin, stomach acid, mucus, inflam response, phagocytic cells specific adaptive: body produces antibodies in response to SPECIFIC antigen through action of B and T lymphocytes. Requires more time, but immune response against that antigen in the future is more efficient

blood pressure classifications

normal 120/80 prehypertension: SBP of 120-139 DBP of 80-89 stage 1: SBP 140-159 or DBP 90-99 stage 2: SBP > 160 or DBP >100 hypotension: SBP < 90

respirations

normal = 12-20 adults 35-40 for infants 20-30 for school age children assess: rate, depth (deep, shallow), rhythm (regular vs. irregular) when chemoreceptors in body detect rising co2 levels, respiratory control center in the brain increases respirations how to take: place pt in semi fowlers place hand on abdomen

pulses

normal range for adults: 60-100 (120-160 bpm for infants) rhythm: regular/irregular equality: right vs. left side pulses strength: 0 (absent) 1 + (diminishes) 2 + (normal) 3 + (strong) 4 + (bounding)

SpO2 (saturation of peripheral oxygen)

normal= 95-100 % low 90s expected for COPD patients

contaminating sterile field

nurse moistens cotton balls and places it in field delayed procedure by 1 hr nurse turns away from field

anxiety, fatigue, powerlessness, insomnia, social isolation

nursing diagnosis may also be the etiology of :

The best way to determine the depth of a patient's respiration is to

observe the degree of chest wall movements during inspiration and expiration -You determine the depth of respiration subjectively by evaluating how much chest wall movement you can observe. The movement is generated by the movement of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansions for the lungs which is usually quite visible

A client who reports SOB requests RN's aid to change positions. While helping, RN's highest priority is

observe the rate, depth, & character of the client's respirations.

when using restraints without an order the nurse must

obtain an order within the hour from the provider, have the prescription be renewed every 4 h for adults, 2 h for kids 9-17, and 1 hr for younger. never leave them unattended when restrained PRN prescriptions for restraints are not allowed

Factors that delay wound healing

old age, decreased immune function, impaired nutrition (especially protein!), decreased perfusion, smoking

factors that delay wound healing

older age,decreased immune function, impaired nutrition (protein), decreased perfusion, smoking

sterile pack on clean surface

open flap farthest from the body

Client is admitted with generalized weakness. At dinner time, the RN should

open the milk & juice containers for the client

Temperature

oral: 36-38 degrees C rectal: 0.5 degrees higher (36.5-38.5 C) axillary: 0.5 degrees lower (35.5-37.5 C) temporal: 0.5 degrees higher (36.5-38.5 C) factors that affect temperature: newborns have lower temps (36.5-37.5 C) older adults have lower temps (average 36 C) increased temp: hormonal changes, exercise, dehydration, illness food, fluids, smoking, can impact oral temp

A RN has organized a discussion session for CNAs about cultural & religious traditions & rituals at the time of death. Nurse determines that one of the participants has a misconception when the CNA states that

organ donation is strictly forbidden by the Baptist Church.

Admission: after gathering assessment data & performing review of systems, next priority is

orient client to room

COPD, difficulty breathing

orthopneic position: sit on side of bed and rest arms over pillows in top of my raised table

urinary elimination

output <30 ml/hour needs to be reported to provider!!! fluid intake should approx. = urine output

hyperthermia

over 39 degrees C obtain blood cultures/specimens admin antibiotics, antipyretics, fluids as ordered prevent shivering provide blankets if pt is having chills

bath tub safety for babies?

parents should never leave their infant or toddler alone in the bathtub, even if they can sit up on their own they are not necessarily safe

stage 2 pressure ulcer

partial thickness loss, involves epidermis and dermis, ulcer is visual abrasion, blister, or shallow crater.

RN shouldn't delegate:

patient education, any task that requires nursing judgement, nursing assessment, blood transfusions

autonomy

patient has the right to make his/her own decision, even if it is not in their best interest

prone bed position

patient is on stomach helps prevent hip flexion contractures after lower extremity amputation

Orthopnic position

patient sits on side of bed with arms on overbid table good for COPD (promotes lung expansion)

Components of a prescription

patients name date/time of prescription name of med strength, dose route time and frequency quality to dispense, number of refills provider signature

a middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

people in middle adulthood often find satisfaction in nurturing and guiding young people

lung assessment

percussion: expected: resonance unexpected: dullness (tumor, pneumonia) hyperresonance: (pneumothorax, emphysema) auscultation: expected: bronchial (trachea), bronchovesicular (over large airways), vesicular (over peripheral areas of lungs) unexpected: crackles (bubbly sounds), wheezes (whistling, musical sounds), pleural friction rub (grating, rubbing sounds)

Nurse is preparing to provide tracheostomy care for patient. Which action should nurse take first? Open all sterile supplies and solutions. Sterilize tracheostomy tube don sterile gloves perform hand hygiene

perform hand hygiene

Nurse hears a scratching sound during both systole and diastole. Sounds become more distinct when client leas forward. How should this sound be documented?

pericardial friction rub

oxygen safety

place "no smoking" sign use cotton bedding and clothes make sure electrical equipment is grounded no extension cords no nail polish

best practices for IV therapy

place arm in dependent position. apply tourniquet 4-6 inches above the insertion site. For older patients, avoid tourniquets (use BP cuff) choose distal veins on non dominant hand avoid varicose veins, veins near valves, veins in flexion areas (AC), veins in back of the hand, hard/sclerosed veins DO NOT place IV on some side as mastectomy, or arm with AV fistula or graft use sterile needle for each insertion attempt. never reinsert stylet into catheter insert catheter at a 10-30 degree angle, bevel up

sterile solutions

place bottle cap face up on sterile surface hold bottle so the label is against your palm pour a small amount (1-2 ml) away when pouring solution, do not touch bottle to site

Endotracheal suctioning

place pt in fowlers or high fowlers catheter diameter should be <= half the diameter of the endotracheal tube hyper oxygenate pt with 100 % O2 and in between suctioning use suction pressure of 120-150 mmHg advance catheter until you reach resistance, pull back 1 cm (above carina) prior to suctioning apply suction intermittently while withdrawing the catheter and rotating it for 10-15 seconds do not reuse suction catheter

NG tubes

place pt in high fowlers agree on signal pt can use if they are feeling distress during procedure lay towel across pt chest use water-soluble lube have pt sip on water while inserting withdrawal slightly if pt gags or chokes check placement by checking pH of gastric contents, confirm placement with XRAY

Taking a rectal temperature

place pt in sims position use lube insert 1-1.5 for adults no rectal temp for babies under 3 mo old or pts with high bleeding risk

sublingual/buccal

place under tongue (sublingual) between check and gum (Buccal) do not eat or drink until dissolved

Hypothermia blanket. The nurse

places a layer of cloth between the client & the blanket

reporting SARS

plan & eval control strageties determing pub health priorities ensure proper med tx monitoring source for outbreak

carseat safety w/ 1 mo. infant

position car seat so that baby is rear-facing

a nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning?

practice sessions

if there is hyper-resonance when percussing a pt's chest what could be wrong?

presence of air, could mean pneumothorax or emphysema

black tissue

presence of eschar that hinders healing and requires removal

yellow tissue

presence of purulent drainage or slough

First aid Bleeding Fractures Sprains Frosbite Burns

pressure to wound splint/neurovascular assessment RICE 98.6-108 degree water to warm up, tetanus remoce agent, elevate extremities, fluids and tetanus

primary prevention

prevents initial occurrence of disease ex: education, immunizations, prenatal classes

planning

prioritize interventions and identify measurable outcomes (time-limited, specific)

nutrition history for dementia pt

priority: any difficult swallowing

hernias look like?

protrusion thru muscle wall,

Nurse on peds is caring for adolescent, name appropriate interventions:

provide a TV & DVDs for him to watch allow him to perform his own morning care

REM sleep

provides cognitive restoration, vivid dreaming, very difficult to awaken, variable vital signs. 20 min. long.

Justice

provides fairness in care and allocation of resources

fats

provides stored energy for the body, provides padding and insulation. important for hormone production and absorption of fat-soluble vitamins makes up 20-35 % of calories provides 9 cal/g of energy

how to change an ostomy pouch

remove pouch, inspect stoma (should be red/pink, moist) and skin (should be intact) clean skin with soap and water, dry thoroughly. do not use moisturizers. CUT OPENING IN SKIN BARRIER <= 1/8 in. LARGER THAN STOMA (NO BIGGER!) Apply skin barrier and pouch, using barrier paste as needed for creases

Hot coffee spills & scalds a client's arm. The nurse's priority action is to:

remove the clothing from the burned area & apply cold water.

how to prevent falls at home?

removing throw rugs or loose carpets, placing electrical cords/extension cords against the walls/behind furniture, place grab bars near toilet/tub or shower, stool riser, non-skid mat in tub/shower, shower chair or bedside commode, lighting is adequate, steps/sidewalks in good shape.

Nurse sleeping

report to nurse manager

Nurse demonstrating postoperative breathing and coughing exercises. The nurse realizes the client may be unprepared to learn if the client

reports severe pain

prevent injury w/ staff

request assistance when repositioning avoid bending at waist smooth movements when move pt

RACE stands for?

rescue alarm contain extinguish

optic drops administration

rest dominant hand on pt forehead drop med into conj sac, without touching eye with the dropper apply gentle pressure to nasolacrimal duct for 1 minute wait 5 min between diff eye drops

purulent drainage

results from an infection, this is thick and contains WBCs, tissue debris, bacteria, foul odor color is what the organism is can be green.

where to heart the aortic valve?

right of the sternum, second ICS

safe med administration

right pt right med right dose right time right route right documentation right pt education right to refuse right assessment (before/after administration) right evaluation

5 rights of delegation

right task right circumstance right person right direction/communication right supervision/evaluation

5 rights of delegation

right task: repetitive, non-invasive, doesn't require much supervision right circumstance: DO NOT assign a pt who is unstable right person: make sure delegate is competent and operating within their scope of practice, check facilities job description. right direction/communication: communicate timeline, expected results, and follow-up communication expectations right supervision/evaluation: intervene if needed, provided feedback

gross motor skills from 6-9 month old

rolls from back to front, bears weight on legs, and sits unsupported

testicular exam

routine health check starting age 20

Types of Prescriptions

routine/standard: given on a regular schedule (give within 30 minutes before or after scheduled time) single/one-time: given once at a specific time. stat: given once immediately Now: given once within 90 minutes PRN: prescription includes dose, frequency, and what under what conditions it can be administered. standing: prescriptions that can be given for specific circumstances on specific units

shaving

safety, if prone to bleeding use electric razor, apply soap/shaving cream, move razor over skin in direction of hair growth using long strokes on large areas and short on small areas, communicate

GCS

scored from 3-15 less than 8= severe head injury/coma between 9-12= moderate head injury eye opening: 4-spontaneous 3 response to voice 2 response to pain 1 no eye opening verbal: 5-coherent/oriented 4-incoherent/disoriented 3- inappropriate words 2 sounds, no words 1- no vocalization motor: 6: follows commands 5-local reaction to pain 4- general withdraw from pain 3-decorticare posture 2 decerebrate posture 1 no motor response

a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take?

select a suction catheter that is half the size of the lumen

symptoms of a systemic infection?

sepsis (change in consciousness, recurrent fever, tachycardia, tachypnea, hypotension, oliguria, increase in WBC count)

a nurse is documenting data about a healing wound on a pts lower leg. the predominant exudate in the wound is watery in consistency and light red in color:

serosanguineous - thin, watery + pink to light red

wound drainage

serous (serum), sanguineous (serum + RBC), serosanguineous (blood, watery), purulent

neurological changes with age

short-term memory loss decreased reaction time decreased senses (vision, hearing, smell, pain, sensation)

actions nurse can initiate

show pt muscle relaxation perform daily bath reposition pt every 2 hrs

glassgow coma scale

shows the levels of consciousness score between 3 and 15 eye verbal motor

In order to facilitate effective communication with child, RN should

sit at eye level with child.

if a pt has a O2 sat reading 90 % or below what to do next?

sit them up to semi or high fowler's position to promote chest expansion, encourage deep breathing, remain with them, confirm probe placement, make sure O2 system if functioning properly.

what is the best position to hear extra sounds and murmurs?

sitting, slightly turned towards left side

Older adult nutrition

slower metabolism, fewer calories needed decreased thirst sensation higher risk for dehydration calcium and vitamin D supplements needed

aspiration risk

small objects out of reach, check toys for small parts/sharp edges, no hard candy, peanuts, popcorn, dont place infant in supine position for feeding or prop their bottle, one piece pacifiers

stress incontinence

small urine loss with abdominal pressure from sneezing, coughing, and laughing

hand hygiene

soap & water: wash hands with antimicrobial soap and water (vs. alcohol based) for these situations: -hands visibly soiled -before eating -after using the restroom -after contact with bodily fluids wash for > = 15 seconds. dry with clean paper towel before turning off faucet. alcohol based product: use 3-5 ml rub until hands are dry

what sounds would you hear auscultating the vesicular area?

soft low pitched, inspiration three time longer than expiration

Ergonomics

spread feet apart to lower center of gravity, which increases stability distribute your weight between the major muscle groups in your arms and legs when lifting when lifting an object, hold it as close to your body as possible avoid twisting or bending at the waist get help when repositioning a pt use smooth movements when moving patients

interventions with pressure ulcer pts.?

stage 1 and 2 can heal on their own with reduction of pressure, maintaining a clean environment, stage two can have a saline dressing or occlusive dressing on it. stage three, clean/debride, prescribed dressing, surgical intervention, analgesics antimicrobials, stage 4: clean/debride, prescribed dressing, surgical intervention, perform nonadherent dressing changes 12 hr, may need skin grafts, hyperbaric oxygen treatment, unstagable: debride until staging is possible.

wound healing

stage 1. non-blanchable erythema (intact skin) stage 2. shallow ulcer (damage to epidermis/dermis) pink/red moist wound bed, no slough stage 3. deeper ulcer (damage to subcutaneous tissue), no exposed muscle, bone, tendon stage 4. deep. exposed muscle,, bone tendon unstageable: eschar, slough covers wound bed, cannot determine wound depth

NREM sleep

stage 1: very light sleep, vital signs and ,metabolism start to decrease, few minutes long stage 2: dapper sleep. vital signs and ,metabolism continue to decrease, 10-20 minutes long. stage 3: beginning of deepest sleep, difficult to awaken. 15-30 min long stage 4: deepest sleep. provides physiologic rest and restoration, vital signs low, very difficult to awaken. sleepwalking/talking possible. 15-30 min long

A nurse assessing a pressure ulcer over a patient's right heel area observes a deep crater with no eschar or slough & no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is:

stage III

screening/assess colorectal screen

start age 50 fecal 1 sigmoid 5 colonoscopy 10 years

oropharyngeal airways

stimulate gag reflex and are only used for clients with altered levels of consciousness. -Supine or semi fowlers

six types of incontinence

stress (when laughing coughing etc) urge (inability to stop urine flow) overflow (retains too much, frequent loss of small amounts reflex (involuntary without warning due to activated muscle) functional (cant get to bathroom in time) total (unpredictable, needs catheter)

Assessment/Data collection

subjective (symptoms) and objective (signs) data always assess before taking action!

trache care?

suction tube if necessary, remove soiled dressing/excess secretions, apply O2 loosely if O2 sat decreases, use cotton tipped applicators and gauze pads to clean exposed outer cannula, clean in a circular motion that starts at stoma site and goes outwards, use surgical asepsis with cleaning inner cannula, clean stoma site then trache plate, replace trache ties if wet or soiled, secure before new ties are removed,

proteins

support tissue building, metabolism, immune function important for wound healing makes up 10-35 % of calories provides 4 cal/g of energy

incentive spirometry

sustained maximal inspiration devices, useful with pts with resp problems or post op pts or bed rest pts measure the flow of air inhaled through the mouthpiece and are used to: -Improve pulmonary ventilation -Counteract the effects of anesthesia or hypoventilation -Loosen respiratory secretions -Facilitate Respiratory gaseous exchange -Expand collapsed alveoli

when doing a resp assessment what are they checking for?

symmetry, cough: productive, color, amount, consistency.

pulmonary embolism (PE)

symptoms: dyspnea, chest pain, increased HR, decreased BP, hemoptysis nursing care: place pt in high-fowlers position administer O2, monitor VS, get ABGs administer thrombolytics or anticoagulants

phlebitis

symptoms: erythema, pain, warmth, edema, indurated, cordlike veins, red steak discontinue IV, elevate extremity, warm compresses, obtain specimen for culture if indicated

IV complications: fluid overload

symptoms: increased BP, JVD, tachycardia, SOB, crackles, edema stop infusion, raise HOB, monitor O2, decrease infusion rate, administer diuretics as ordered

catheter embolus

symptoms: missing, catheter tip when removing IV, severe pain with migration place tourniquet high on extremity, prepare patient for removal of tip w/ X-ray or surgery

IV complications: Cellulitis

symptoms: pain, warmth, edema, induration, red streak, fever, chills, malaise. stop infusion, remove IV, elevate extremity, warm compress, obtain specimen for cultures. admin antibiotics, analgesics, antipyretics as ordered

Infiltration

symptoms: swelling around site, edema, coolness, dampness, slowed rate of infusion discontinue IV, elevation, warm/cold compress

fluid volume excess

symptoms: tachycardia, tachypnea, hypertension, bounding pulses, weight gain, dyspnea, crackles, edema, JVD labs: decreased hct decreased serum osmolarity decreased urine specific gravity (1.01), unless SIADH decreased electrolytes, BUN, creatinine nursing care: weigh daily, restrict fluids and sodium as ordered, administer O2 and diuretics, prevent skin breakdown

Fluid Volume Deficit (FVD)

symptoms: tachycardia, tachypnea, hypotension, weak pulse, fatigue, weakness, thirst, dry mucus membranes, GI UPSET, OLIGURIA, decreased skin turgor, decreased capillary refill, diaphoresis, flattened neck veins labs: increased hct increased serum osmolarity increased urine spec. gravity >1.03 hypernatremia >145 mEq/L nursing care: weigh daily, provide fluid replacement, report urine output <30 ml/hr to provider, assist w/ ambulation (prevent falls)

DVT (deep vein thrombosis)

symptoms: unilateral edema, pain, warmth, erythema in leg interventions: elevate leg, administer anticoagulants as ordered pt teaching: increase activity and change positions as much as possible immobility increases the risk of DVTs perform antiembolic stockings every 2 hrs: ankle pumps, foot circles, knee flexion AVOID: pillow under knees, crossing legs, wearing restrictive clothing, sitting for a long time, or massaging legs wear SCDs or anti embolic stockings (remove every 8 hrs to assess skin)

systemic vs local infection

systemic- fever, chills, malaise, fatigue, increased RR, increased pulse local- edema, pain, erythema, warmth in particular area of body lab tests that indicate infection: WBC > 10,000 Left shift (immature WBC) ESR > 20 CRP > 3 Positive culture result- get culture before starting antibiotics!!

infection

systemic: fever, chills, malaise, fatigue, increased RR, increased HR local: edema, pain, erythema, warmth in particular area lab tests: WBC > 10,000 left shift, immature WBCs ESR>20 CRP>3 POSITIVE CULTURE (GET BEFORE STARTING ANTIBIOTICS)

cardio system with aging?

systolic hypertension due to atherosclerosis, CVD, CO decreases, peripheral circulation decreases, heart valves stiffen

symptoms of fluid volume deficit

tachycardia, tachypnea, hypotension, weak pulse, fatigue, weakness, thirst, dry mucus membranes, GI upset, oliguria, decreased skin turgor, decreased cap refill, diaphoresis, flattened neck veins

Early signs of hypoxemia?

tachypnea, tachycardia, restlessness, anxiety, pale skin, mucous membranes, elevated blood pressure, use of accessory muscles, nasal flaring, etc.

orthostatic hypotension

take BP in supine position. sit patient up and wait 2-3 minutes. take pt BP sitting. stand patient up and wait 2-3 mins. take BP standing POSITIVE: SBP decrease >20 DBP decrease >10 with 10-20% increase in HR

after seizure

take VS perform neuro checks reorient pt identify possible trigger implement seizure precautions (pad bed rails)

radial pulse

take on thumb side of wrist regular-30 sec irregular: 1 min

orthostatic hypotension

take pts blood pressure in supine position sit pt up and wait 2-3 minutes take BP sitting stand up pt and wait 2-3 minutes take BP standing

prevention of respiratory complications

teach pt to turn, cough, breathe deeply every 1-2 hrs while awake encourage use of incentive spirometer increase fluid intake to 2,000 ml/day (unless restricted) reposition every 1-2 hrs

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take first?

tell the client to keep the head of the bed elevated at least 30 degrees

acute pain

temporary, protective, resolves with tissue healing. patients may exhibit: tachycardia, hypertension, anxiety, diaphoresis

Ethnocentrism

the belief that one's own culture is superior to all others. view world from own cultural viewpoint nurses should not demonstrate this

a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse?

the caregiver insists on remaining in the room

lung recoil

the continual tendency of the lungs to collapse away from the chest wall

tidal volume

the degree of chest expansion during normal breathing is minimal, requiring little energy expenditure. in adults, approximately 500 ml of air is inspired and expired with each breath

lung compliance

the expansibility or stretchability of lung tissue

what does fluid in the abdomen look like?

the flanks protrude, protrusion moves with dependency

Orthopnea

the inability to breathe easily unless sitting upright or standing.

trachea and lungs, with the branchioles, alveoli, pulmonary capillary network, and pleural membranes

the lower respiratory system includes

a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

a nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining blood pressure?

the one close to 120 mm Hg

a nurse is caring for a client who reports pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

the pain is like a dull ache in my stomach

pulmonary ventilation, aveolar gas exchange, transport of oxygen and carbon dioxide, and systemic diffusion

the process of the respiratory system include

The difference between a pt's systolic and diastolic BP is called

the pulse pressure

postural drainage

the use of various positions to promote gravity drainage of bronchial secretions; coughing usually expels secretions of the trachea.

how often should a catheter line/peri area be cleaned per day?

three times with soap and water and after pooping

prodromal stage

time from the onset of general symptoms (malaise, fatigue) to specific symptoms.

convalescence

time from when symptoms disappear to complete recovery (can take months)

incubation

time from when the pathogen enters the body until the first symptom appears.

skin changes with age

tinnier, translucent skin loss of elasticity hair thinning decreased sweating, oil production (increased dryness) decreased subcutaneous tissue over bones (high risk of pressure injuries) larger pigmented spots (age spots, liver spots) blood vessel fragility (easy bruising, bleeding)

nasopharyngeal airways

tolerated better by alert clients. they are inserted through the nares, terminating in the oropharynx

Age related findings on an older adult client:

tooth loss glare intolerance thickened eardrums

nurse actions during disasters

tornados: close shades, move away from windows (hallway), place blankets over pt who is bedbound chemicals: undress pt, irrigate profusely. for dry chemicals: brush chemical off clothing or skin hazardous materials: locate SDS. water is universal antidote in most cases. bomb threat: keep caller on phone as long as possible, listen for background noises, clues

Graphesthesia

trace a number on a patients hand, ask them to identify it

wheal

transient, elevated, irregular borders, edematous, often pruritic (insect bites)

Intradermal med admin

tuberculin syringe 26-27 gauge small volume 0.01-0.1 ml insert bevel up at 10-15 degree angle observe for small bubble and do not massage the site

Patient being admitted to long term care facility requires total care. In providing oral care, the appropriate nursing action is:

turn the client on his side before starting mouth care

left lung has how many lobes

two

A provider has prescribed restraints for a client who is agitated. When applying restraints, the nurse would put the client at risk by

tying the restraint with a knot that cannot be easily undone.

expected sound when percussing over abdomen?

tympany over most, low pitch tympany over upper left quad due to liver

Water seal

type of chest tube system that looks like a box and stays upright and below level of chest consists of 2 cm of water, enough to submerge the bottom of the tube & create a one-way valve--water seal allows for the fluid to come out of & not to return to the patient's chest.

hypothermia

under 35 degrees C provide warm blanket warm IV fluids increase room temp keep head covered

BMI ranges

underweight: <18.5 normal: 18.5-24.9 overweight: 25-29.9 obese: >30

symptoms of deep vein thrombosis

unilateral edema, pain, warmth, erythema in leg intervention: elevate leg, anticoagulants avoid pillow under knees, crossing legs, wearing restrictive clothing, sitting for a long time, massaging legs perform exercise every 2 hours- ankle pumps, foot circles, knee flexion

inability to reach bathroom in time due to overactive detrusor muscle

urge incontinence

antihistamines and anticholinergics can cause?

urinary retention

Anticholinergic effects from meds

urinary retention, constipation, dry mouth, blurry vision, photophobia, tachycardia -patient teaching: increase fiber and fluid intake, wear sunglasses outside

minimum urinary output per hour

urine output < 30 ml/hr needs to be reported to provider!

IM injections admin

use 1-1.5 in, 18-27 gauge needle -use vastus lateralis for infants <= 1 year old -volumes over 2ml: ventrogluteal site -deltoid site limited to volume up to 1 ml -inject at 90 degree angle with Z-track method

irrigation of wound

use 30 -60 ml syringe, 5-8 psi pressure

injury prevention in school age children

use car booster seat while child is under 4'9" or under 40 lbs use protective gear for bicycling, sports reduce water heater settings to less than 120 degrees F keep guns locked up, bullets stored in a separate location enclose pools with locked fence, supervise children

Chest physiotherapy (CPT)

use percussion, vibration, postural drainage to loosen secretions schedule treatments 1 hr before or 2 hrs after meals to avoid vomiting administer bronchodilator or nebulizer 30 min-1 hr prior to CPT

Urine glucose testing

used to test for ketones in urine recommended for diabetic patients during times of illness, stress, or when they have blood glucose > 240 mg/dl

mucus clearance device

uses vibration to help loosen mucus in patients with COPD or cystic fibrosis

The most important factor in measuring blood pressure accurately is

using a cuff of the appropriate size for the patient

Within the context of the nurse client relationship, congruence on the part of the nurse implies

using communication tools in a genuine & spontaneous manner

what is the S3 heart sound indicate?

ventricular gallop, use bell to find it

nursing care of NG tubes

verify tube placement with X-ray before feeding first time verify presence of bowel sounds before feeding check gastric contents pH (should be between 0-4) discard bags/tubing every 24 hrs measure gastric residual every 4-6 hrs, return residual to stomach hold feeding for residual over hospital policy (~500 ml) flush feeding tubes with 30 ml of water every 4 hrs formula should be at room temp

thrills (heart)

vibration associated with murmurs or other cardiac abnormalities

thrills

vibration associated with murmurs or other cardiac abnormalities.

a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend?

walking briskly

Hand-washing

wash hands w/ soap and water for at least 15 sec use clean paper towel to turn off faucet

transdermal med administration

wash skin with soap and water, dry thoroughly place patch on hairless area rotate sites use gloves when applying

transdermal administration

wash skin with soap and water, dry thoroughly. PLACE PATCH ON HAIRLESS AREA. Rotate sites. use gloves

water soluble vitamins fat soluble vitamins

water- C, Bcomplex fat- A, D, E, K

a nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advance directives. which of the following responses should the nurse make?

we can talk about advance directives, and i can also give you some brochures about them

abdomen with age?

weaker muscles, rounder more protruding, can have inflammation and rebound tenderness, saliva and gI secretions/pancreatic enzymes decrease, slower GI motility and peristalsis.

a nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

what could i have done to deserve this illness?

a nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending the stairs, i will first shift my weight to my right leg

evisceration

when sutures rupture open an d the internal visceral organs protrude through the wound opening.

when can kids sit in the front seat?

when they are older than 12 yrs

Surgery to home transfer

where to go for follow-up care instructions for diets/meds contact info for home healthcare agency

whisper test (hearing test)

whisper from 1-2 ft away while occluding 1 ear (don't let pt see your mouth move)

tertiary intention healing

widely separated, deep, spontaneous opening of previously closed wound, risk of infection. -extensive drainage, tissue debris, closed later, long healing time.

a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take?

withhold the blood transfusion

a nurse is caring for a client who requires consent for a surgical procedure. which of the following actions is the nurse's responsibility?

witness the client's signature on the consent form

Wound Healing: Tertiary Intention

wound left open to address infection and then close at a later time

a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care?

wrap blankets around all four sides of the bed

a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take?

wrap monitoring cords with stockinette and tape them in place

a nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does this involve?" which of the following responses should the nurse make?

you should have a fecal occult blood test every year

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

you should receive a pneumococcal immunization every 10 years

nurse is caring for pt who has developed a stage I pressure ulcer in the area of the R ischial tuberosity which should nurse apply

zinc oxide - it is a barrier cream

aerosol mask

10L/min provides high humidified o2 also used with tracheostomy collar.

for school age children, reduce water heating setting to less than ___ degrees F

120

sodium

135-145 mEq/L

SODIUM function in body

136-145 mEq/L maintains fluid balance in the body, nerve and muscle function

clients who can move independently should move every...?

15 mins

The nurse should flush the feeding tube with_______mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with _______mL of sterile water following the administration of the last medication.

15-30 30-60

Semi-Fowler's Position

15-45 degrees (usually 30) prevents aspiration, and helps ventilation

catheter sizes

16 G-trauma patients 18 G-surgery patients or those receiving blood 22-24-gauge for other patients

catheter sizes

16 gauge for trauma patients 18-20 gauge for surgery pts or those receiving blood 22-24 gauge for other patients

A nurse is performing an admission assessment on a client. The nurse determines the clients radial pulse rate is 68/ min and the simultaneous spica pulse rate is 84/ min. What is the pulse deficit?

16/min

key conversions for dosage calculations

1mg = 1,000 mcg 1 g = 1,000 mg 1 oz = 30 ml 1 tsp = 5 ml 1 tbsp= 15 ml 1 tbsp = 3 tsp 1 kg = 2.2 kg 1 gr = 60 mg

Pt. is to receive 12.5 mg of prednisone (Deltasone) by mouth daily. med is available in 5 mg tablets. How many tablets should nurse administer for ea. dose?

2 tablets (WRONG) **2.5 tablets

enteral feeding tubes: cover and label unused formula with patient information, refrigeration for up to ___ hours

24

correct use of crutches

3 finger widths between axilla and top of crutch, elbows flexed 30 degrees walking (non-weight bearing)- start in tripod position. advance both crutches and the injured leg, then move unaffected

POTASSIUM function in body

3.5-5.0 maintains ICF, nerve function, regulates muscle and heart contractions

subQ admin

3/8-5/8 inch 25-27 gauge needed. or use insulin syringe 28-31 gauge if admin insulin. inject volumes up to 1.5ml in fatty areas at a 45-90 degree angle. use 90 degree angle for obese patients