Exam 3 PrepU

Normal WBC count

4,000-10,000

Neutrophils

50-70%

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap.

What organ is the primary site of heat loss in the body?

Skin

What is the most common client site for development of healthcare-associated infections (HAI)?

Urinary (catheters)

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

provides quick access to abnormal findings

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

reporting

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?

1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

Monocytes

4-8%

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% of the circumference of the limb to be used

Routine order

Administered until the health care provider discontinues the order or until a prescribed number of doses or days have occurred.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

Auscultate the patient's apical pulse

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation?

Charting by exception

Which charting formats permit documentation on any significant topic, not just client problems?

FOCUS

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

The nursing is caring for a client who requests to see a copy of his health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the Problem, Intervention, and Evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (Problem), antiemetic given (Intervention), no further vomiting (Evaluation).

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

A nurse manager is conducting an in-service education program about client records and documentation for a group of nurses working on the medical-surgical unit. After teaching the group about this topic, the nurse determines that the teaching was successful when the group identifies which aspect as the primary purpose of client records?

communication

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?

contact

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

elevating the client's arm at heart level

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

lace a surgical mask on the client and transport to the CT department at the specified time.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?

noncommunicable

standing order

written in advance of a situation that is to be carried out under specific circumstances