fundamentals
A nurse is providing discharge teaching. Which response indicates an understanding of the teaching?
"A nurse will show me how to care for my wound."
NG tube removal
- disconnect tube from suction - inject 50 mL air to clear contents - instruct client to hold breath - pinch tube
tracheostomy suctioning
- hyperoxygenate w 100% O2 for at least 2 minutes prior to suctioning - perform max of 3 passes - give 1 min in bt/wn suctioning passes to hyperoxygenate - pull suction catheter back 0.5 inch if client starts coughing
NG tube feeding
- keep HOB elevated for 1 hour after feeding - flush 30 mL water before & after - inject 10-30 mL air before checking residual to clear of any food - to assess placement prior to admin, check residual & verify pH (want less than/equal to 4)
Hold dropped ___ inches above ear to administer otic meds
0.5
hold irrigator ___ inches away from the eye
1
normal gastric pH
1-4, can be up to 6
magnesium
1.3-2.1 mg/dL
BUN
10-20 mg/dL
Infant should be able to use utensils to feed themselves by
12 months
sodium
135-145 mEq/L
move cane
15-30 cm forward before each step
How long to wait between inhalations of bronchodilating inhalers?
20-30 seconds
HCO3- range
21-28 mEq/L
how often to use ROM to improve mobility
2x daily
Do not take oral temp on children less than
3 yo
phosphorus
3.0-4.5 mg/dL
potassium
3.5-5.0
1 oz
30 mL
PaCO2 range
35-45 mmHg
BP cuff bladder should be
40% arm width
WBC
5,000-10,000/mm3
ABG pH range
7.35-7.45
blood glucose levels
70-110 mg/dL
BP cuff should be
80% arm circumference
PaO2 range
80-100 mmHg
Infant should be expected to use pincher grasp at
9 months
calcium levels
9-10.5 mg/dL
calcium
9.0-10.5 mg/dL
Angle to use when capillary blood glucose testing (finger prick)
90
hypomagnesemia
<1.3 mEq/L
hyponatremia
<135 mEq/L
hypokalemia
<3.5 mEq/L
hypocalcemia
<9 mg/dL
hypercalcemia
>10.5 mg/dL
hypernatremia
>145 mEq/L
hypermagnesemia
>2.1 mEq/L
hyperkalemia
>5.0 mEq/L
A nurse is administering meds to a client who asks the nurse to leave the med at the bedside to be taken at a later time. What should the nurse reply? A. "Call me when you are ready and I will return with the med." B. "Since you were taking this med at home, I will leave it for you to take." C. "I will come back in 30 mins to check that you took the med so I can chart the time." D. "If you refuse to take the med now, I can't give it again until your next scheduled time."
A. "Call me when you are ready and I will return with the med." - other answers incorrect; B - nurse responsible for med admin, C - nurse can't verify med was taken, D - med can generally be given w/in 1 hour of prescribed time
+1 pitting edema bilaterally. mm indentation? A. 2 B. 4 C. 6 D . 8
A. 2 mm - +2 = 4 mm, +3 = 6 mm, +4 = 8 mm
A nurse is planning a training session about nutrition. Which statement should she include in the teaching? A. Fats provide energy B. Carbs repair body tissue C. Fats regulate fluid balance D. Carbs prevent interstitial edema
A. Fats provide energy - this is true, the rest are false (A, B, & C relate to protein)
A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take A.) Explain that it is against policy to share access codes and refer the resident to his supervisor. B.) Access the client's online data and monitor the resident as he reads it. C.) Access the online client data system and allow the resident to locate the client's data. D.) Ask the client to give permission for the resident to access his medical records.
A. explain that it is against policy to share access codes & refer the resident to his supervisor - allowing unauthorized access is a breach of federal guidelines for data security & client confidentiality
A nurse is providing teaching to a client with HF about reducing his daily sodium intake. Which factor is most important in determining the client's ability to learn new dietary habits? A. the involvement of the client in planning B. the emphasis the provider places on the dietary changes C. the learning theory the nurse uses to teach the dietary changes D. the extent of the dietary changes planned for the client
A. the involvement of the client in planning - according to EBP, client involvement is the most important factor in the client's ability to learn new habits
A nurse is caring for a client who has injuries resulting from a motor vehicle crash. Which statement should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."
B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." - Maslow's hierarchy; need for comfort, pain management
Which client is eligible for hospice services at this time? A. a client who has MS and uses a wheelchair B. a client who has end-stage liver cirrhosis C. a client who has hemiplegia due to a stroke D. a client who has cancer and receives weekly radiation therapy
B. a client who has end-stage liver cirrhosis - likely has life expectancy of <6 months
A nurse is performing an admission assessment for a client who has asthma and reported several food allergies. Which action should the nurse take first? A. document the client's food allergies in the medical record B. ask the client to identify the specific food allergies C. monitor the client for indications of anaphylaxis D. have epinephrine available for administration
B. ask the client to identify the specific food allergies - data collection/assessment before developing a plan of action
A nurse is teaching about pain management in clients age 65 and older. Which piece of info should she include? A. clients who are age 65 and older experience a decreased ability to perceive pain B. clients who are age 65 and older are reluctant to report pain C. clients who are age 65 and older should not receive opioid narcotics D. clients who are age 65 and older experience a shorter duration of action with medications
B. clients who are age 65 and older are reluctant to report pain - other answers incorrect; 65+ clients are frequently reluctant to report pain bc they might not want to bother/anger caregivers & might believe pain is expected
A client has terminal illness. What indicates that their death is imminent? A. urinary retention B. cold extremities C. hypotension D. tachycardia
B. cold extremities
A HHN is visiting an older client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working and caring for his mother at home. Which option should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult day care facility
C. Respite care - respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance
A nurse is inserting an IV catheter for a client that results in blood spilled on her gloved hand. The client has no documented blood infection. Which action should the nurse take? A. wash the gloved hands, then throw the gloves away B. prepare an incident report C. carefully remove the gloves and perform hand hygiene D. ask the provider to order a blood culture to determine the risk of infection
C. carefully remove the gloves and perform hand hygiene - standard precautions
A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which action should the nurse take first? A. obtain the prescribed irrigation solution B. don personal protective equipment C. check the client's pain level D. place a waterproof pad under the client's extremity
C. check the client's pain level - collect data/assess before intervening; A is incorrect bc you should have the solution prior to performing the procedure
A nurse is administering a cleansing enema to a client before a diagnostic procedure. What action should she take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. position client on the 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) - nurse should insert tip of tube 7-10 cm (3-4 inches) along the rectal wall to prevent tube dislodging during the procedure/ A - lubricate 5-8 cm (2-3 in); B - Sims'; D - hold container a max of 45 cm (18 in) above the rectum to prevent painful distension of the colon
A nurse is caring for an inmate. The inmate is brought in by a guard who asks about the client's HIV status. What should the nurse do? A. inform the guard that the warden must request this info B. ask the guard to sign a release of info form C. instruct the guard to ask the inmate D. complete an incident report
C. instruct the guard to ask the inmate - rest incorrect, client consent !!!
A nurse is caring for an adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which action should the nurse take? A. tie the restraints to the side rails B. perform ROM exercises to the wrists every 3 hrs C. remove the restraints one at a time D. obtain a PRN prescription for the restraints
C. remove the restraints one at a time - remove restraints one at a time for a violent/noncompliant client
A nurse is preparing to irrigate a client's wound. Which action should she take? A. use a 10 mL syringe B. attach a 22 gauge catheter to the syringe C. warm the irrigating solution to 37 Celsius D. administer an analgesic 10 min before the irrigation
C. warm the irrigating solution to 37 Celsius - rest are incorrect
A nurse is performing a spiritual assessment of a client. Which question should the nurse ask? A. "When did you start to believe in your faith?" B. "How often do you perform religious rituals?" C. "Which church do you regularly attend?" D. "What is your source of strength and hope?"
D. "What is your source of strength and hope?" - broad, open-ended question, does not assume
A nurse is discussing fire safety with newly hired nurses. Which action is the priority if a fire occurs in a health care facility? A. Close the fire doors on the unit B. Use a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit
D. Evacuate clients from the unit - the greatest risk during a fire is injury to clients; therefore the nurse's priority action is to evacuate clients from the unit
Client has head of the bed at 45 degrees with his knees slightly flexed. Which position is he in? A. Sims B. Prone C. Supine D. Fowler's
D. Fowler's - aka Semi Fowler's, which is between 45 -60 degrees
A nurse is preparing to administer a TB skin test. After performing hand hygiene, which action should the nurse take? A. select a 23 gauge needle B. insert the needle into the skin at a 25 degree angle C. massage the area of injection following removal of the needle D. circle the injection area with a pen
D. circle the injection area with a pen - circling the area ensures the nurse will examine the correct site when reading the test 48-72 hours later
A nurse is caring for a client who is unstable and has vital signs measured every 15 mins by an electronic BP machine. The nurse notices the machine begins to measure the BP at varied intervals and the readings are inconsistent. What action should the nurse take? A. turn on the machine every 15 min to measure the client's BP B. record only the BP readings needed for 15 min intervals C. obtain manual & automatic readings & compare them D. disconnect the machine & measure the BP manually every 15 mins
D. disconnect the machine & measure the BP manually every 15 mins - malfunctioning equipment can pose a safety risk
A nurse is performing a mental-status exam on a client who has manifestations of dementia. What directions should the nurse give the client to evaluate their ability to think abstractly? A. subtract by 7 serially, starting at 100 B. describe a previous illness C. explain what to do if a fire happened in his bedroom D. discuss the meaning of a common proverb
D. discuss the meaning of a common proverb - A. evaluates attention span, B. evaluates remote memory, C. judgement
While admitting a client to the unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which document? A. informed consent form B. living will document C. DNR directive D. durable power of attorney document
D. durable power of attorney document - AKA health care proxy, names surrogate who can make health care decisions if client is unable to do so
A nurse manager is providing teaching to a group of nurses about ways that clients acquire health care associated infections (HAIs). Which route of infection should the manager identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure
D. infection acquired from a diagnostic procedure - iatrogenic HAIs result from diagnostic/therapeutic procedures
sodium regulates
ECF volume
A nurse is auscultating a client's lungs and identifies rhonchi over the trachea & bronchi. What should the nurse do?
Encourage the client to cough - rhonchi typically caused by obstructions/excretions
What should a nurse wear when in contact with a client with AIDS?
Gown & gloves
hyponatremia s&s
N/V, headache, confusion, muscle cramps, seizures, coma, DEPRESSED DTRs, hypothermia, tachycardia, high HR, hypotension
Should you let the family/friends of a patient who speaks a different language than the nurse relay medical info to the client?
NO, medical interpreters are federally mandated
4 clients on oxygen therapy. Partial rebreather, transtracheal oxygen cannula, tracheostomy collar, nasal cannula; priority?
Partial rebreather client - if bag doesn't inflate properly, client will rebreathe CO2
fluid volume excess symptoms
Peripheral edema, weight gain, bounding pulse, elevated BP, distended veins, dyspnea, crackles, confusion, altered LOC
temporal artery temperature
Temperature taken on either side of the head, where the temporal arteries are located
Placed soiled linen in
a single linen bag
Before suctioning a client's tracheostomy, the nurse should
administer high-flow O2 - reduces risk of hypoxia
use PC for
after meals
Muscle group responsible for knee movement
antagonistic
A nurse is taking vitals. This action is which component of the nursing process?
assessment - collecting data = assessment
Infant should be able to crawl on hands and knees
at 9 months
2+
average
don't BT for
bedtime
Brain's respiratory control center
brainstem, medulla, pons
3+
brisk
ecchymosis
bruise
salivary amylase breaks down
carbohydrates
balance/coordination problems r/t
cerebellum
A client is having difficulty with coordination after a head injury. The nurse should suspect damage to which area of the brain?
cerebellum - coordinates voluntary movements
difficulty w/ expression r/t
cerebral cortex
Clean blood spills with
chlorine bleach
clubbing of nails is caused by
chronic hypoxemia
What food can cause a false negative guaiac test
citrus
example of concrete operational thought
collecting and trading game cards - requires seriation (what to collect, what to trade, what has value)
MRSA precautions
contact (gloves - if splashing, mask, gown)
after using IS
cough deeply
most accurate measurement of fluid status
daily weight
reduce orthostatic hypotension/fall risk by
dangling legs on edge of bed for 60 seconds
Client has calcium level of 12.7 mg/dL. What finding should the nurse expect?
depressed DTRs, NV, bone pain, lethargy, weakness
St. John's wort
depression
1+
diminished
xerostomia
dry mouth due to lack/absence of saliva
Symptoms of protein malnourishment
dry, brittle hair, edema, poor wound healing
How often to move extremities to promote circulation
every 1-2 hrs
pap smear
every 3 years, starting at 21
A nurse is called away for an emergency. She returns promptly to the client as promised. Which ethical principle is she demonstrating?
fidelity - keeping promise
positive pressure airflow
filters the air going into the room; used in patients who have compromised immune systems
kidneys regulate
fluid volume, electrolytes, acid-base balance
Clean surgical wound
from the wound toward the surrounding skin (least to most contaminated/dirty)
obstruction of the flow of the vitreous humor in the eye is a manifestation of
glaucoma
don't use HS for
half-strength
chamomile
has anti-inflammatory properties
metabolic alkalosis
high pH, high HCO3
respiratory alkalosis
high pH, low CO2; hyperventilation
urticaria
hives (allergic reaction)
Dressing to put on stage II pressure ulcer
hydrocolloid - absorbs exudate, provides moist environment that facilitates healing
4+
hyperactive
Prolonged exposure to stress can cause
hyperglycemia and hypertension
metabolic acidosis r/t
hyperkalemia
hypoactive DTRs
hypermagnesemia, hypernatremia, hyponatremia, hyperkalemia, hypokalemia, hypercalcemia
positive Chovstek
hypocalcemia
metabolic alkalosis r/t
hypokalemia
hyperactive DTRs
hypomagnesemia, hypocalcemia
sleep difficulty r/t
hypothalamus
strabismus
improper alignment of the eyes
concrete operational stage
in Piaget's theory, the stage of cognitive development (from 7 to 11 years of age) during which children gain the mental operations that enable them to think logically about concrete events
garlic, ginger, & ginkgo biloba
increase risk of bleeding; DON'T use w/ anticoagulant
edema at infusion site
indicates IV infiltration, fluid entering SQ tissue
Use half-strength hydrogen peroxide to clean
inner cannula of tracheostomy
spooning of nails (koilonychia) is caused by
iron deficiency
Raising all 4 side rails
is considered a physical restraint; prescription from provider needed for nurse to employ
When ambulating with a cane, the client should
keep 2 points of support on the ground at all times
4 point crutch gait
keep 3 points on the ground at all times
To maximize heat loss in a client with a fever, the nurse should
keep their bed linens dry
Client position for enema
left Sims'
rhonchi
loud coarse or snoring sounds; caused by obstructed airways
respiratory acidosis
low pH, high CO2; hypoventilation
metabolic acidosis
low pH, low HCO3
Where to anchor catheter tube on a male
lower abdomen/upper thigh (with tape)
black cohosh
mimics estrogen; may be used in pts going thru menopause
A nurse is caring for a client who had a stroke and is at risk of falling. What should the nurse do?
monitor the client at least once every hour, keep bed in low position, create elimination schedule, use gait belt when client is ambulating
A client reports SOB. After repositioning, which action should the nurse take next?
observe the rate, depth, & character of the client's respirations - before an intervention, nurse needs to collect data (assess)
To assess for pulse deficit
obtain apical & radial pulses simultaneously; subtract the difference
insensible fluid loss
occurs daily through lungs and skin; cannot be measured for accurate output
When feeding a client with dysphagia, the nurse should
offer the client sour/tart foods first - stimulates saliva production
What equipment should be at the bedside of an seizure patient?
oxygen
To check for strabismus, the nurse should
perform a corneal light reflex test
Procedure education can ONLY be done by
physician
A client reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes the wound has eviscerated. What should the nurse do?
place the client in a supine position with hips and knees flexed; cover wound and intestine with a sterile, moistened dressing; monitor client for manifestations of shock
Dextran and albumin are
plasma volume expanders (correct hypovolemia)
postural drainage
positioning a patient so that gravity aids in the drainage of secretions from the lungs
negative pressure airflow
prevents contaminated air from inside the room from flowing outside the room
iatrogenic
produced by a treatment
valerian
promotes sleep
saw palmetto
prostate
How to straighten ear canal in children younger than 3 yo
pull auricle back and down
When mixing regular insulin w/ NPH
pull regular 1st bc it's short acting while NPH is intermediate
8-10 month old can
pull self to standing position
hypertension screening is an example of
secondary prevention
Braden scale
sensory perception, moisture, activity, mobility, nutrition, friction and shear
postop client should use IS
several times an hour
4 month old
should be able to sit up w/ support w/ no head lag
What nutrient regulates extracellular fluid volume?
sodium
echinacea
stimulates immune system
The nurse is caring for a client with a peripheral IV catheter. He notes that the area surrounding the insertion site is red and warm. What should the nurse do?
stop infusion, remove IV catheter, apply warm compress to site
don't use SC for
subcutaneously
Infiltration S/S
swelling, discomfort, burning, tightness, cool skin, blanching
An assessment reveals a client has a temp of 39.2 C (102.6), HR of 105, soft nontender abdomen, and menses overdue by 2 days. Which finding should be the nurse's priority?
temperature of 39.2 C - elevated HR could be caused by fever, therefore fever is 1st priority
When providing oral care for an unconscious client, the nurse should
test for client's gag reflex - determines aspiration risk; many clients w/ decreased LOC do NOT have gag reflex
Tape a catheter on a female client to
the inner thigh
Never use a client's room number to ID them because
they can change rooms
How often to wash feeding bag
twice a week
safest injection site
ventrogluteal
Which breath sound should the nurse expect to hear over the periphery of the major lung fields?
vesicular
3 point gait is used
when patient is non-weight bearing on a leg
Change smoke detector batteries every
year