coursepoints teset 1 foundations

Nursing Interventions

Activities that the nurse plans and implements to help the patient achieve identified outcomes

A nurse works with an older adult client who has two broken femurs. The client does not report pain. Which action will the nurse take?

Assess the client for nonverbal cues of pain.

A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

The nurse is trying to obtain a temperature and the client continues to bite down on the oral thermometer. The nurse determines a rectal thermometer should be used. What actions demonstrates the nurse's understanding of the client's well-being and safety during this procedure?

Using a digital thermometer, the nurse inserts the covered, lubricated probe 1.5 in (3.75 cm) into the rectum for 1 minute.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 30 minutes before measuring the oral temperature

brachial artery

artery of the upper arm

brachial artery

artery of the upper arm; the site of the pulse checked during infant CPR

There is an auscultatory gap.

assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds.

The least accurate method for taking a temperature is

axilliary

Which pulse site is generally used in emergency situations?

cartoid

apnea

cessation of breathing

medical asepsis

clean technique

In which population should the nurse recognize an increased risk for infection? Select all that apply.

debilitated clients older adults clients with impaired skin integrity

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?deep in the posterior sublingual pocket

deep in the posterior sublingual pocket

dyspnea on exertion

difficulty breathing upon movement/ambulation

Pyrexia

fever

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown, gloves

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

handwashing

rectal temperature

he most accurate measurement, based on core body temperature.

A nurse teaches a student nurse the importance of ambulating clients to prevent the effects of immobility on body systems. What is one of these effects?

impaired circulation

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

increased pulse rate

eupnea

normal breathing/respiration

apical pulse

pulse taken with a stethoscope and near the apex of the heart

What anatomic site regulates the pulse rate and force?

sa node

A nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use?

sedation

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk?

shearing force

Droplet precautions

spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask)

surgical asepsis

sterile technique

Airborne precautions

tb measles, chickenpox (varicella) Herpes zoster/shingles TB

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

the ability of the arteries to stretch

cartoid pulse

the heartbeat found on each side of the neck

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

thigh

pedal pulse

top of foot

The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action does the nurse identify that appropriately reflects these movements?

turns the arms downward and then upward

cartoid artery

one of the two major blood vessels that travel up the sides of the neck to supply the brain

What is an average normal temperature in Celsius for a healthy adult?

oral- 37c

Standard Precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.

The client experiences intractable chronic pain from cancer. The nurse is developing a care plan to provide the client adequate pain relief. What principle(s) will guide the treatment plan? Select all that apply.

Administer pain medications around the clock. Give oral medications for pain relief. Assess the client's pain experience at every visit. Contact the health care provider if the client reports unrelieved pain.

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply.

Encourage the client to stand up from a sitting position slowly. Ensure that the client is taking an adequate volume of fluids. Assist the client in applying compression stockings to lower extremities. Ask the client to wait 1 hour after meals to engage in physical activity.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

Provide privacy for the client.

Biot's respirations

Rapid and deep respirations followed by 10 to 30 seconds of apnea

Which statement accurately represents a consideration when using an epidural analgesia for client pain management?

The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min.

The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching?

The client sits in the chair with feet flat on the floor and arm below the level of the heart.

Pain is an invisible phenomenon influenced by the interaction of affective, behavioral, cognitive, and physiologic-sensory factors. Which statement about pain perception is true? Select all that apply.

The gate control theory of pain transmission was developed by Melzack and Wall. Pain threshold is the highest intensity of pain that a person is willing to tolerate. Allodynia is a pain sensation produced by an innocuous stimulus such as light touch. Suffering is an emotional response associated with increased pain.

radial artery

The major artery in the forearm; it is palpable at the wrist on the thumb side.

peripheral pulses

The radial, brachial, posterior tibal, and dorsalis pedis pulses, which can be felt at peripheral (outlying) points of the body.

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?

airborne

A nurse is caring for a client who has influenza and varicella. Which type of transmission precautions should the nurse follow when caring for the client? Select all that apply

airborne contact droplet

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

alcohol swab

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

assisting the client in moving to prevent strain on the suture line

vital signs

blood pressure pulse temperature respiratory rate

orthopnea

difficulty breathing when lying down, breathe better sititng up

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?

diligent handwashing practices

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

endorphins

isometric exercise

exercise in which muscle tension occurs without a significant change in muscle length

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

lightly compress the client's radial artery, using the first, second, and third fingers

contact precautions

measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

nalaxone

A nursing instructor is describing different types of infection in different age groups. What would the instructor describe as being particularly common in the older adult? Select all that apply.

urinary tract infections (UTI) respiratory tract infections influenza infections