Exam 1 Study Guide

A client at an outpatient psychiatric clinic has been experiencing anxiety. The nurse would like to suggest activities for the client to do in his/her spare time. What would be an appropriate activity for the nurse to suggest to the client? Select all that apply. Taking up a hobby Board games Daily walks Bingo Stretching exercises

Daily walks Stretching exercises Taking up a hobby

TRUE OR FALSE Inflammation and infection are the same thing.

False

Contact Precautions are used for patients whose infection is spread by direct contact, like _________, _______, and ___________

Herpes Simplex, MRSA, and RSV

Nosocomial infections are acquired: - in the home - in the workplace - in the hospital - in the ER

Hospital

Put the stages of infection in order: Illness stage Incubation period Prodromal stage Convalesence

Incubation period Prodromal stage Illness stage Convalescence

FEVER __________ the immune response Helps to eradicate ___________ that thrive at lower body temperatures Enhances the effects of __________ ___________ the plasma iron concentration _________ the growth of microorganisms

Mobilizes, organisms, antibiotics, Decreases, Limits

Prone best helps the _______________ system

Musculoskeletal

Planning involves ___________ exposure to infectious organisms Controlling or __________ the extent of infection Verbalizing understanding of infection prevention and control techniques (e.g., ______ ________)

Preventing, reducing, hand hygiene

What can we teach our patients? REEDA, which stands for :

Redness Edema Ecchymosis Drainage Approximation

Bacterial organisms present in the blood defines _____________

bacteremia

TJC & CMS dictate that a restraint must be medically ordered , and other _______ restrictive interventions are attempted first

less

Restraints must be removed every ______ hours

two

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? Place the client in semi-Fowler's position while feeding. Stop the feedings and check for residual volume. Be sure liquid nutrition is at room temperature Elevate the head of the bed to 30 degrees

Stop the feedings and check for residual volume. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician.

When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client states: "I will not remove the dressing until I return to the clinic next week." "My husband will change the dressing three times per week, using sterile technique. "I will monitor my temperature once every other day." "I know it is very important to wash my hands after irrigating the catheter."

"My husband will change the dressing three times per week, using sterile technique.

A client tells the nurse that "the hospital food is horrible." What should the nurse tell the client? "The staff is doing the best it can to cook in such large quantities." "I will report this to the health care provider." "Would you like to speak with the dietitian about the food and meal selection?" "I don't like the hospital cafeteria food either."

"Would you like to speak with the dietitian about the food and meal selection?"

A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs? Egg yolks. Brown rice. Vegetables. Tea.

Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up. Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she will not need to hear. Call the surgery unit to explain the client's concern, and ask if she can wear her hearing aid to surgery.

Call the surgery unit to explain the client's concern, and ask if she can wear her hearing aid to surgery.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? Instruct the client not to move while the restraints are in place. Remove the restraints every 4 hours to provide skin care. Secure the restraints to side rails of the bed. Check on the client every 30 minutes while the restraints are on.

Check on the client every 30 minutes while the restraints are on.

Types of baths include: ___________ Bed Bath P_______ Bed Bath Sponge bath at sink Tub bath __________ P__________ care Bed bath/Travel bath Bag bath

Complete, partial, Shower, Perineal

A multiparous client and her neonate, who has been cared for in the intensive care nursery for the past 3 days because of being small for gestational age, are to be discharged. Before their release, the mother tells the nurse, "I have been living in my car for the past 2 weeks." What should the nurse do next? Notify the director of the birthing unit. Contact the hospital's social worker. Contact the client's primary care provider. Notify any of the client's family members.

Contact the hospital's social worker.

Infections are classified according to ___________ and duration. A. Organism B. Geography C. Body system D. Location

D. Location

Assessment includes a thorough investigation: _______ collection, Subjective and Objective Data

DATA

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? Decreased urine output Deficient fluid volume Impaired urinary elimination Fluid volume excess

Deficient fluid volume

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation? Cover by assessing the first nurse's patients hourly. Nothing; the first nurse's patients did not call for assistance. Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Ask the nurse on the day shift to report the situation to the nurse manager.

Discuss the situation with the first nurse, including the safety implications of sleeping on the job.

A nurse manager is auditing the nursing unit's adherence to infection control practices. Which of the following observations causes the nurse manager to be most concerned that the clients on the unit are at risk for infection? A nurse does not wear a mask when entering the room of a client on contact precautions. Hand hygiene is forgotten between clients by several nurses on the unit. A nurse does not use sterile scissors to cut the tape for a wound dressing. A client receives a prophylactic antibiotic 20 minutes late.

Hand hygiene is forgotten between clients by several nurses on the unit.

Which strategy can help make the nurse a more effective teacher? Including the client in the discussion Using technical terms Providing detailed explanations Using loosely structured teaching sessions

Including the client in the discussion

Nosocomial Infections: (select all that apply) Caused by viral agents Infection acquired in a health care setting Results from delivery of health services in a health care setting Most nosocomial infections are spread through the hands of healthcare providers

Infection acquired in a health care setting Results from delivery of health services in a health care setting Most nosocomial infections are spread through the hands of healthcare providers

Name the six links of the Chain of Infection IA SH PEn MT PEx Res

Infectious agent, susceptible host, portal of entry, mode of transmission, portal of exit, reservoir.

Primary defenses of the immune system include: Intact skin Strong WBC count Good genetics Great hand washing technique

Intact skin

Cholesterol includes ______, or the 'bad' cholesterols

LDL

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? Take vital signs Monitor the appearance, size, and number of stools. Measure BUN and serum creatinine levels Measure intake and output

Monitor the appearance, size, and number of stools.

__________ ___________ occurs when the intake and output of nitrogen are equal.

Nitrogen balance

The Nursing Process is concerned with ___________ Priorities

Nursing

The parents of a 15-year-old female with a history of disordered eating are concerned about her loss of 24 lb (10.9 kg) during the previous month. The nurse tells the parents that she'll give their daughter a comprehensive examination and make appropriate referrals. Which initial referrals should the nurse make? Select all that apply. Dental assessment Gynecologic examination Nutritional consult Psychiatric evaluation Toxicology evaluation

Nutritional consult Psychiatric evaluation

Clinical Manifestations of inflammation include: (select all that apply) - Pain - Bleeding - Redness - Warmth - Drainage - Rash - Malaise - Anorexia - Fever - Diarrhea - Bruising

Pain, Bleeding, Redness - Warmth - Drainage - Rash - Malaise - Anorexia - Fever - Diarrhea

Building blocks for cells and tissues

Protein

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which type of diet should the nurse discuss? high-residue diet low-sodium diet regular diet high-protein diet

Regular diet. For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.

CDC Guidelines: Tier One: ___________ Precautions Tier Two: ____________ Based Precautions

Standard, Transmission

A nurse working in a physician's office observes a physician sneeze into his/her hand as he/she is walking from one examination room to another. The physician does not wash his/her hands before entering the room to examine the next client. What is the nurse's first priority? Tell the physician to wash his/her hands before examining the client. Assume the physician knows whether he/she is contagious. Have the client wash his/her hands after the doctor's examination. Tell the client to come back if symptoms of sneezing begin.

Tell the physician to wash his/her hands before examining the client.

A non-English-speaking client with chest pain has been admitted to the health care facility. Because the assigned nurse does not know the client's language, what would be the most appropriate solution in this case? The nurse should request the help of a professional interpreter. The nurse should get a language dictionary and translate. The nurse should ask the supervisor to assign some other client. The nurse should communicate with the client non-verbally.

The nurse should request the help of a professional interpreter.

An infectious disease is caused by micro organisms, True or False

True

Increases the flow of __________, nutrients & __________ to the area

WBCs, oxygen

Interventions for equipment related malfunction include Seek ________, No clutter in rooms, and Label and send for ________

advice, repair

A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first: encourage the client to increase oral fluid intake. insert an intermittent urinary catheter. notify the health care provider (HCP). assist the client up to the toilet to attempt to void.

assist the client up to the toilet to attempt to void. Urinary retention is common following surgery with anesthesia, following childbirth, or as a result of specific medication use, for example narcotics for pain. Clients should be assisted to an anatomically comfortable position to void prior to resorting to more invasive methods such as intermittent or indwelling catheterization to manage urinary retention. Difficulty voiding after child birth is expected, and it is not necessary to notify the HCP. While increasing fluid intake is important, it will not help the client void now.

Which nursing action is most important in preventing cross-contamination? changing gloves immediately after use standing 2 feet (61 cm) from the client speaking minimally when in the room wearing protective coverings

changing gloves immediately after use

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply. whole wheat bread cooked dry beans peanut butter yogurt apple

cooked dry beans yogurt peanut butter

Inflammatory Exudate is Accumulation of the fluid, WBC's and _______ ________ ______ form an __________ at the site of the inflammation

dead tissue cells, exudate

Airborne Precautions are used for patients whose disease is transmitted by airborne _________, like TB, measles and chickenpox

droplets

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: restores the inflammatory response. enhances oxygen transport to tissues. reduces edema. enhances protein synthesis.

enhances protein synthesis.

Four clients in a critical care unit have been diagnosed with Psuedomonas aeruginosa. The Infection Prevention and Control Department has determined that this is probably a nosocomial infection. Select the most appropriate intervention by the nurse. The nurse should: wear an N-95 mask when caring for the four clients. initiate transmission-based precautions. initiate contact precautions. ensure that staff members do not have artificial fingernails.

ensure that staff members do not have artificial fingernails.

Intervention: Managing Nutritional Imbalances, must identify the __________ of the imbalance

etiology

D, A, K, E are _____ soluble vitamins, _________ can occur

fat, toxicity

Protein helps maintain ________ balance

fluid

Precautions include clean ______ and ________ when you anticipate any contact with the patient or with any contaminated items in the room

gown, gloves

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: fresh orange slices. ground beef patties. steamed broccoli. ice cream.

ground beef patties. Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

It is important for nurses to communicate with clients about their health care because: consumers of health care cannot keep up with rapid advances in science. health care services are often specialized and fragmented. the media provides misleading information. clients are more demanding that their rights be respected.

health care services are often specialized and fragmented.

Proteins combine with iron to form __________ (binds to oxygen)

hemoglobin

CDC recommends Transmission Based Precautions for protection if a patient has a diagnosed or suspected ________ ____________ disease

highly communicable

Secondary defenses - during the complement cascade, Triggers release of inflammatory mediators such as ____________

histamine

Inflammation begins with ____________ and leads to _____________

histamine, vasilodation

A wound infection is an example of a wound isolated to a region or area of the body, or a _____________ infection

localized

Immune compromised clients include: Patients with ______ WBC's, Patients with cancer undergoing ___________ Large open __________

low, chemotherapy, wounds

Wear a ______ and ___ protection when working within 3 feet of the patient

mask, eye

Good body ___________ can help prevent hazards

mechanics

NPO is a SPECIAL DIET that means

nothing by mouth

Regarding Never Events, ____________ is key

prevention

NG Tube Placement, ________ verification - most reliable, Used to verify initial placement

radiographic

Communicate clearly with team members. Incorporate patient's priorities. Move from the cleanest to less clean areas. Ex: head to toe. If bedbound, feet upward. Change wash water from the waist up. Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood. Test the temperature of water or solutions. Use principles of body mechanics and safe patient handling. Be sensitive to the invasion of privacy. Are all __________ guidelines

safety

Term that describes symptomatic systemic infection in the blood is __________

septicemia

An 18-year-old pregnant woman tells the nurse that she is concerned that she may not be able to take care of herself during her pregnancy. She states that she is not sure what prenatal care is available, or if she should access it. The nurse should recognize that the client: may not take care of herself. may not be fit to take care of a child. needs to take up a second job. should be referred to community resources available for pregnant women.

should be referred to community resources available for pregnant women

A nurse tells a client that she will come back in 10 minutes to re-assess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing? Empathy Sympathy Trust Closure

trust

Keep bed comfortable, dry linen, free of ____________

wrinkles

Standard precautions or Universal Precautions are valid for ____ patients Some A few All Most

All

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans, hamburger, and milk

Which of the following theories of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? Care-based ethics. Deontology. Utilitarianism. Principle-based ethics.

Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology, utilitarianism, and principle-based ethics each prioritize goals and principles that exist beyond the particularities of the nurse-client relationship.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? Limit salt intake to 2000 mg a day Encourage a high calorie, high protein diet

Encourage a high calorie, high protein diet

Defense against infection includes the body's natural defenses such as: (select all that apply) Flora RBCs Body system defenses antiseptic wipes inflammation

Flora Body system defenses inflammation

Communicable disease is: Illness directly or indirectly transmitted from one person to another OR Illness caused by a microorganisms

Illness directly or indirectly transmitted from one person to another.

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed? Administer a prescribed analgesic 10 minutes prior to getting out of bed. Position the client on his or her side for 5 minutes. Have the client flex and extend the feet while in a recumbent position. Place the client in a high Fowler's position.

Place the client in a high Fowler's position.

Bathing improves _____________, and provides an opportunity to make ______________

circulation, assessments

A client has received numerous different antibiotics and now is experiencing diarrhea. The health care provider (HCP) has prescribed a transmission-based precaution. The nurse should institute: airborne precautions. contact precautions. droplet precautions. needlestick precautions.

contact precautions.

To prevent back injuries, use assistive __________ and help from others

devices

Prevention includes: ______ risk assessment Increase frequency of __________ Keep beds in ____ position Keep call bell in _______

fall, rounds

Poor Vision Cognitive Impairment Difficulty with walking and/or balance Orthostatic Hypotension Weakness or dizziness Drowsiness from medications Are risk factors for ________

falls

Implementation: Prevention of Falls include Asking a _________ ________ to stay with patient

family member

After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings: meet the fluid and nutritional needs of the client. prevent aspiration. prevent fistula formation. maintain an open airway.

meet the fluid and nutritional needs of the client.

Droplet Precautions are used when the pathogen can be spread via moist droplets from sneezing, coughing, talking, laughing... like Influenza, Pertussis, _________

mumps

Accidental Death in the US - Unintentional Poisoning is the ______ _____ cause of accidental death for all age groups

number one

Client hygiene includes bathing, ________ care and ___________ care

oral, perineal

Guidelines for bathing include: Maintain _________, and Wash from _______ to __________

safety, distal to proximal

In a Protective Environment, Medical equipment that stays in the room includes the _________, blood pressure ______, and ____________

stethoscope, cuff, and thermometer

The most comfortable position is _________

supine

Standard Precautions apply to blood, body fluids, secretions, excretions, non-intact skin and mucous membranes. They do not apply to ________

sweat

A ___________ infection is carried by the bloodstream, and effects the entire body.

systemic

When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications? Essential amino acid deficiency. Essential fatty acid deficiency. Hyperglycemia. Infection.

Infection

Which disciplines should be consulted when caring for a client with a stage III heel ulcer? Nutrition support and orthotics Physical therapy and respiratory therapy Occupational therapy and infectious disease Plastic surgery and cardiology

Nutrition support and orthotics

Define Pathogen

Organism capable of causing disease Infectious Agent

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take? Continue to monitor and record hourly urine output. Notify the physician. Irrigate the indwelling urinary catheter. Increase the I.V. fluid infusion rate.

Continue to monitor and record hourly urine output.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? Painful skin that is swollen and pale in color Cold, red skin Small, localized blackened area of skin Red, swollen skin with inflammation spreading to surrounding tissues

Red, swollen skin with inflammation spreading to surrounding tissues

The Chain of Infection is made of ____ links 4 5 6 7

six

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: eat three well-balanced meals per day. exercise 1 hour before each meal. take a vitamin and mineral supplement. divide daily food intake into five or six meals.

divide daily food intake into five or six meals.

Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as prescribed. What should the nurse do first? Ask the client's spouse to insist that the client take the deep breaths every 2 hours. Respect the client's wishes, and turn the client from side-to-side more frequently. Suggest that the client increase the daily fluid intake to at least 2,500 mL. Explain the risks of not expanding the lungs and why the exercise is important.

Explain the risks of not expanding the lungs and why the exercise is important.

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? Determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly Identifying who will be responsible for making client care decisions Deciding what type of dress code will be implemented Identifying salary ranges for various types of staff

Identifying who will be responsible for making client care decisions

A nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should: keep the area covered with the warm soaks. remove the warm compress for at least 15 minutes after each 20-minute application. alternate warm compresses with cold compresses. question the order because heat increases edema.

Remove the warm compress for at least 15 minutes after each 20-minute application. Because heat and cold can injure the skin, either should be applied for only a limited time. Warm compresses increase circulation and promote fluid absorption in the infiltrated area. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction. Cold compresses, which help reduce edema, cause vasoconstriction. Keeping the area covered continuously can lead to skin breakdown.

A nurse who is preparing to boost a client up in bed instructs the client to use the over bed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? Friction Impaired circulation Localized pressure Shearing forces

Shearing forces. Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? chicken and orange slices cheeseburger and french fries cheese omelet and bacon gelatin salad and tea

chicken and orange slices. Protein and vitamin C are particularly important in promoting wound healing and recovery from infection. A diet high in carbohydrates is also essential. Because the client with an infection commonly does not feel like eating, it is important that what the client eats should be nutritious. Chicken and orange slices would help meet the client's protein and vitamin needs. A meal of cheeseburger and fries or cheese omelet and bacon is high in fat and do not contain as much vitamin C as the chicken and orange slices. Gelatin salad and tea contain minimal nutrients.

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? preservation of muscle mass prevention of bone demineralization increase in muscle tone maintenance of joint mobility

maintenance of joint mobility

A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is: wearing gloves. administering antibiotics. washing hands. assigning clients to private rooms.

washing hands.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? providing passive range of motion exercises to the left extremities during the bed bath elevating the foot of the bed to reduce edema pulling up the client under the left shoulder when getting the client out of bed to a chair putting high top tennis shoes on the client after bathing

pulling up the client under the left shoulder when getting the client out of bed to a chair

The client with kidney stones refuses to eat lunch and rudely tells the nurse to get out of his room. Which response by the nurse is most appropriate? "I will leave, but you need to eat." "I will get you something for your pain." "Your anger does not bother me. I will be back later." "You sound angry. What is upsetting you?"

"You sound angry. What is upsetting you?"

A client who has been using crutches at home for 1 week reports having trouble using the crutches because the armpits hurt and the fingers tingle. The nurse should tell the client: "You need to do more arm exercises. It sounds like your muscles need strengthening." "That is normal. As you adjust to the crutches, the discomfort will diminish." "Be sure to take your pain medication before ambulating. That will help your discomfort." "Let me watch you ambulate. Your crutches or technique may need some adjustment."

"Let me watch you ambulate. Your crutches or technique may need some adjustment."

Reservoir

A place where the pathogen grows and reproduces

Infections are classified as: (select all that apply) Acute Chronic Latent Emergent

Acute Chronic Latent

A postpartum client tells the nurse she's having trouble moving her bowels. The nurse should recommend that she do which of the following to combat constipation? Eat more cheese. Maintain bed rest and avoid exercise. Add more vegetables to her diet. Limit fluid intake to 32 oz (1 L) daily.

Add more vegetables to her diet

Factors that support Host Defenses include: (select all that apply) Adequate nutrition Balanced hygiene Rest/exercise Immunizations Break the chain of infection to prevent infection Hand sanitizer

Adequate nutrition Balanced hygiene Rest/exercise Immunizations Break the chain of infection to prevent infection

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine?

Albumin level

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? Apply a water-soluble lubricant to the nares. Reposition the tube Irrigating the tube with a cool solution Help the client change position in bed

Apply a water-soluble lubricant to the nares

The nurse has been assigned to a client who is hearing impaired and reads speech. Which strategies should the nurse incorporate when communicating with the client? Select all that apply. Avoid being silhouetted against strong light. Do not block out the person's view of the speaker's mouth. Face the client when talking. Have bright light behind so the individual can see. Ensure the client is familiar with the subject material before discussing. Talk to the client while doing other nursing procedures.

Avoid being silhouetted against strong light. Do not block out the person's view of the speaker's mouth. Face the client when talking. Ensure the client is familiar with the subject material before discussing.

A nurse is assessing a postoperative client. Which information should the nurse document as subjective data? Vital signs Laboratory test results Client's descriptions of pain Electrocardiograms (ECGs)

Client's descriptions of pain

An elderly woman has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO." Based on this order, what action should the nurse take? Apply oxygen by nasal prongs if necessary. Ensure that the client does not eat or drink anything. Ensure that the client's record is made available to any private health insurance provider she has. Insert a nasogastric or oropharyngeal tube if necessary.

Ensure that the client does not eat or drink anything.

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? The time of day when exercise is performed isn't important. Exercising in the evening before going to bed is beneficial. Exercising immediately upon awakening allows the client to participate in activities when he has the greatest amount of energy. Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided.

Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values? Integrity. Altruism. Social justice. Human dignity.

Integrity

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate? Placing the client in Trendelenburg position Placing the client in Sims' position Placing the client in high Fowler's position Placing the client in the supine position

Placing the client in high Fowler's position

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection? Inadequate secondary defenses Impairment of primary body system defenses Chronic disease Proper nutrient intake

Proper nutrient intake

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? Monitoring his temperature every 4 hours Increasing fluid intake Covering the client with a light blanket Providing a low-calorie diet

Providing a low-calorie diet. Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever.

A 19-year-old primigravid client is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which interventions? Select all that apply. Refer client to a nutritionist for the following day. Ensure that the client has a prescription for an antiemetic. Ask the health care provider (HCP) for an anxiolytic prescription. Encourage return to normal routine when client feels ready. Coordinate follow-up appointment with provider in 6 weeks. Discuss plan of care and discharge instructions with client.

Refer client to a nutritionist for the following day. Ensure that the client has a prescription for an antiemetic. Encourage return to normal routine when client feels ready. Discuss plan of care and discharge instructions with client.

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet? regular clear liquid full liquid soft

Regular. Dietary management following rehydration for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet.

Which concept refers to a professional nurse's role in client advocacy? The nurse makes decisions for clients who can't make decisions for themselves. The nurse follows the basic standards of care and hospital policies and procedures for providing client care. The nurse promotes and protects the client's interests and rights. The nurse adopts a paternalistic approach to client care.

The nurse promotes and protects the client's interests and rights.

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment? Speech therapist. Respiratory therapist. Physical therapist. Physician

Speech therapist. The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of speech therapists. The physician should be made aware and respiratory therapy may be involved with assessing and promoting the client's oxygenation, but swallowing assessment is a task most often performed by a speech therapist.

The nurse walks into a client's room to administer the 0900 medications and notices that the client is in an awkward position in bed. What is the nurse's first action? Ask the client his name. Check the client's name band. Straighten the client's pillow behind his back. Give the client his medications.

Straighten the client's pillow behind his back. The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his name and checking his armband, so that the medication can be administered.

Which would be most likely to assist the client with hypertension in maintaining an exercise program? Give the client a written exercise program. Explain the exercise program to the client's spouse. Reassure the client that he or she can do the exercise program. Tailor a program to the client's needs and abilities.

Tailor a program to the client's needs and abilities.

The nurse recognizes that the goals established for a client's discharge are more likely to be accomplished when: The client assists in developing the goals. The physician develops the goals. The nurse develops the goals. The multidisciplinary team develops the goals.

The client assists in developing the goals.

True or False, Infectious diseases are commonly communicable, or passed from one person to another

True

Soil, water and ____ can also be a reservoir for an infectious agent

food

A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer? "Do all your chores in the morning, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up." "Pace yourself and rest frequently, especially after activities." "Do all your chores in the evening, when pain and stiffness are least pronounced."

"Pace yourself and rest frequently, especially after activities."

The parents of an ill child are concerned because the child "is not eating well." Which strategies are appropriate to encourage the child to eat? Select all that apply. Allow the child to choose meals from an acceptable list of foods. Let the child substitute items on the tray for other nutritious foods. Ask the child to say why he or she is not eating. Remind the child he or she must eat in order to get better. Request that the parents not be present when the child is eating.

Allow the child to choose meals from an acceptable list of foods. Let the child substitute items on the tray for other nutritious foods. Ask the child to say why he or she is not eating.

A client is being discharged with nasal packing in place. The nurse should instruct the client to: perform frequent mouth care. use normal saline nose drops daily. sneeze and cough with mouth closed. gargle every 4 hours with salt water.

Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.

As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first? Recommending warm milk or a warm shower at bedtime Gathering more information about the client's sleep problem Determining whether the client is worried about something Finding out whether the client is taking medication that may impede sleep

Gathering more information about the client's sleep problem

A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner? Hold the cane on the left side 4 to 6 inches (10 to 15 cm) from the base of the little toe. Hold the cane away from the body. Move the cane and the right leg simultaneously. Hold the cane in the right hand.

Hold the cane in the right hand. To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4 to 6 inches (10 to 15 cm) from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, and then move the uninvolved leg.

A community health nurse is planning to address the physical needs of older adults living in their homes. What primary areas would be included in this discussion? Importance of exercise, balanced nutrition, mobility and safety needs Assessment of mobility patterns and ways to prevent joint deterioration and falls Social support systems and ways to prevent hearing and visual deficits Importance of frequent physician visits and access to health care resources

Importance of exercise, balanced nutrition, mobility and safety needs

A nurse is developing a care plan for a client with injury to the frontal lobe of the brain. Which nursing actions would be part of the care plan? Select all that apply. Keep instructions simple and brief because the client will have difficulty concentrating. Speak clearly and slowly because the client will have difficulty hearing. Assist with bathing and toileting because the client have vision disturbances. Orient the client to person, place, and time as needed because the client will have memory problems. Assess vital signs frequently throughout the nursing shift because vital bodily functions will be affected.

Keep instructions simple and brief because the client will have difficulty concentrating. Orient the client to person, place, and time as needed because the client will have memory problems.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize? Legumes Lean meats and low-fat milk Cheese Vegetables

Lean meats and low-fat milk. Protein promotes healing.

During the entry phase of a home visit, the nurse is likely to perform which of the following tasks? The nurse calls to make initial contact with the client and schedule a visit. The nurse gathers supplies and equipment needed for the first visit. The nurse obtains directions to the client's home. The nurse establishes nursing diagnoses for the client.

The nurse establishes nursing diagnoses for the client.

A nurse is caring for an Asian-American client after arthroplasty. The nurse plans to help the client ambulate, but is aware that the client may feel threatened by physical closeness. What would be the most appropriate nursing action? Let the client ambulate slowly on his own when he is stable. Explain the purpose and need for assistance during ambulation. Instruct family members to ambulate the client. Ambulate the client without answering his questions.

The nurse should explain the purpose of ambulation, and the need for assistance while ambulating, to the client. This would relieve his anxiety associated with physical closeness. However, the client won't be able to ambulate without assistance. Even though the nurse can instruct a family member to ambulate the client, this is not an appropriate action. Ambulating the client without answering the client's question is non-therapeutic, as the nurse would be performing a procedure without giving adequate explanation.

The nurse is preparing for the admission of a client on a stretcher. In what position should the nurse place the bed? Highest position. Lowest position. Middle position. High Fowler's position.

The nurse would place the bed in the highest position if the client will arrive on a stretcher. For ambulatory clients, the bed should be in the lowest position. The High Fowler's position is often used for clients with respiratory difficulties.

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. To prevent fractures, the client should avoid strenuous exercise. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

The recommended daily allowance of calcium may be found in a wide variety of foods.

Professional regulations and laws that govern nursing practice are in place for which of the following reasons? To limit the number of nurses in practice To ensure that practicing nurses are of good moral standing To protect the safety of the public To ensure that enough new nurses are always available

To protect the safety of the public

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? I'd like orange juice, bran muffin, and apple slices. Today I can have apple juice, chicken broth, and vanilla ice cream. I would like bacon, eggs, and coffee

Today I can have apple juice, chicken broth, and vanilla ice cream.

The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. To assure adequate nutrition, what should the nurse instruct the client to do? Select all that apply. Weigh weekly and report weight loss. When eating, sit and lean slightly forward. Have serum albumin level checked regularly. Administer enteral tube feedings as ordered. Manipulate the nasogastric tube daily.

Weigh weekly and report weight loss. When eating, sit and lean slightly forward. Have serum albumin level checked regularly. Administer enteral tube feedings as ordered.

A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in her part-time employment, states that she is very concerned about her 20-lb (9.1-kg) weight gain since she started taking the medication 6 months ago. The nurse should: suggest that the client talk with her healthcare provider about changing to another antipsychotic. advise the client to decrease her dosage by one-half. tell the client not to worry because she should stop gaining weight. discuss nutrition, daily diet, and exercise with the client.

discuss nutrition, daily diet, and exercise with the client.

When giving a change of shift report, which statement by the nurse is not appropriate? "Randi Smith is a 38-year-old female client of Dr. Born with cholecystitis and cholelithiasis." "Mrs. Jones' pain is best relieved in the left lateral Sims position." "Mr. Levi is just contrary today, and nothing is going to please him." "Mr. Emmert was able to walk around the unit twice today with no report of dizziness."

"Mr. Levi is just contrary today, and nothing is going to please him."

The nurse instructs the unlicensed assistive personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which technique should the nurse ask the UAP to incorporate into the client's daily care? Assess the oral cavity each time mouth care is given and record observations. Use a soft toothbrush to brush the client's teeth after each meal. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours. Rinse the client's mouth with mouthwash several times a day.

A soft toothbrush should be used to brush the client's teeth after every meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the UAP. Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.

The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. The nurse should first: Obtain a 12-lead ECG. Administer pain medication. Allow the client to rest for a few minutes, then re-assess. Request new activity prescriptions from the health care provider (HCP).

Allow the client to rest for a few minutes, then re-assess.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate? Reexplain to the client why she cannot drink. Offer ice chips every hour to decrease thirst. Offer the client frequent oral hygiene care. Divert the client's attention by turning on the television.

Offer the client frequent oral hygiene care.

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do? Perform arm circles while riding in the car. Perform ankle pumps and foot range-of-motion exercises. Elevate her legs while riding in the car. Take an ambulance home.

Perform ankle pumps and foot range-of-motion exercises.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should: administer TPN through a nasogastric or gastrostomy tube. handle TPN using strict aseptic technique. auscultate for bowel sounds prior to administering TPN. designate a peripheral intravenous (IV) site for TPN administration.

handle TPN using strict aseptic technique.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment? free, easy movement of the joints absence of paralytic footdrop external rotation of the hips at rest absence of tissue ischemia over bony prominences

free, easy movement of the joints

Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client's: diabetic neuropathy. muscle atrophy. Raynaud's disease. transient ischemic attacks.

diabetic neuropathy

To ensure safety for a hospitalized blind client, the nurse should: require that the client has a sitter for each shift. require that the client stays in bed until the nurse can assist. orient the client to the room environment. keep the side rails up when the client is alone.

orient the client to the room environment.

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? Primary prevention Secondary prevention Tertiary prevention Passive prevention

primary prevention

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? pulse rate blood pressure body temperature respiratory rate

pulse rate

A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse her concern that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best? "Your friends are going to figure something out when the weight starts coming off." "I'm not at liberty to discuss your case with anyone except those directly involved in your care, unless you authorize me to do so." "I can't lie to your friends if they ask me." "I'll avoid allowing your friends to ask me questions."

"I'm not at liberty to discuss your case with anyone except those directly involved in your care, unless you authorize me to do so."

A client says he'd like to stay in contact with a nurse who's discharging him and asks if she'd meet him for coffee. The nurse's best response is: "Thank you, but it's important that we maintain a professional relationship." "I'm not allowed to fraternize with anyone who has been my client." "I'll have to see if your physician feels our meeting would be beneficial for you." "I'm really not interested in meeting with you outside the hospital."

"Thank you, but it's important that we maintain a professional relationship."

A worried mother confides in the nurse that she wants to change primaryhealth care providers (HCP's) because her infant is not getting better. What is the nurse's best response? "This primary care provider has been on our staff for 20 years." "I know you are worried, but the primary care provider has an excellent reputation." "You always have an option to change. Tell me about your concerns." "Your infant's condition takes time to heal."

"You always have an option to change. Tell me about your concerns."

Regarding use of restraints, Order must be renewed every ____ hours

24

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care? All plans have the same values underlying the delivery of care. Their values are not reflected in the decision making. All systems reflect the values of efficiency and effectiveness. There are no conflicts between cost-effectiveness and respectful care.

All systems reflect the values of efficiency and effectiveness.

Three Precautions are used for these specific patients Based on means of transmission Con_____ Precautions Air______ Precautions _______let Precautions

Contact Airborne Droplet

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which of the following infection control practices does the nurse consider most important for this client? Diligent adherence to aseptic technique Using antimicrobial soap when providing care Requesting prophylactic antibiotic treatment Implementing respiratory isolation procedures

Diligent adherence to aseptic technique

Which guidelines define and regulate what the nurse may and may not do as a professional? State legislature Facility policies and procedures Standards of care Nurse practice act

Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

During the assessment of a client's mouth, the nurse notes the absence of saliva. The client reports having pain behind the ear. The client has been nothing-by-mouth (NPO) for several days, but now can have liquids. The nurse should: request an order for an antifungal mouthwash. instruct the client to brush the gums as well as the teeth. encourage the client to suck on hard candy. give the client a hydrogen peroxide based mouthwash.

Encourage the client to suck on hard candy. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client are indications that the client may be developing parotitis, or inflammation of the parotid gland. Parotitis usually develops with dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventive measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care.

________ density lipoproteins (HDL) remove cholesterol from the bloodstream to liver where it is used to produce bile.

High

The delivery of culturally competent nursing care incorporates the concept of: Planning and implementing care in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations. Challenging the beliefs and values of clients from diverse cultures. Recognizing that the healthcare system is void of culture and cultural imposition must occur. Ethnocentrism into the delivery of care.

Planning and implementing care in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations.

The main priority in preventing infection is Implementing medical __________ procedures asepsis droplet prevention sterility

asepsis

Oral hygiene for an unconscious client includes prevent _____________, turn them on their side

aspiration

Negative nitrogen balance occurs with ___________, burns, malnutrition

illness

Protective, or Reverse Isolation is for __________ ___________ clients

immune-compromised

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate? blood glucose screening for diabetes diet and exercise for people with heart disease immunizations for influenza range of motion exercises

immunizations for influenza

Airborne Precautions: Private room Or with a patient with an active infection caused by the same organism and no other ____________

infections

Eyes - Clean from ________ to __________ canthus

inner, outer

Hygiene for our clients important? Prevent infection Prevent skin breakdown Protects skin ___________ Promotes and overall feeling of _______ ______

integrity, well being