Fundamentals of Nursing - Physiological Aspects of Care

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? 1 Pulse rate 2 Tissue turgor 3 Specific gravity 4 Body temperature

2 Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decreas

A health care provider prescribes an intravenous (IV) infusion of ampicillin 375 mg every six hours. The drug is supplied as 500 mg of powder in a vial. The directions are to mix the powder with 1.8 mL of diluent, which yields 250 mg/mL. How much prepared solution should the nurse administer? Record the answer using one decimal place. ___ mL

1.5 Use the "Desire over Have" formula to solve the problem. Desire 375 mg = x mL Have 250 1 mL 250x = 375 X = 375 ÷ 250 X = 1.5 mL

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1 Sunken eyes 2 Dry, flaky skin 3 Change in mental status 4 Decreased bowel sounds

3 Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin and decreased bowel sounds, because these can be prominent as general normal findings in the elderly client.

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? 1 Inspect and palpate in the epigastric region. 2 Auscultate and percuss in the inguinal areas. 3 Percuss and palpate in the hypogastric region. 4 Percuss and palpate bilaterally in the lumbar areas.

3 To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, percussing and palpating in the hypogastric region or bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.

A client is receiving heparin sodium intravenously at 1,500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number. ___ mL

240 mL 25,000units/500 mL = 50 units/mL 1 mL/50 units x 1,500 units/hour 30 mL/hour x 8 hours = 240 mL

What should the nurse do initially when obtaining consent for surgery? 1 Describe the risks involved in the surgery. 2 Explain that obtaining the signature is routine for any surgery. 3 Witness the client's signature, which the nurse's signature will document. 4 Determine whether the client's knowledge level is sufficient to give consent.

4 Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. Describing the risks involved in the surgery is not within nursing's domain. Although obtaining a signature is routine, explaining that obtaining the signature is routine for any surgery does not determine the client's ability to give informed consent. Although witnessing the client's signature will be done, the nurse first should assess the client's knowledge of the surgery.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1 Orient the client to the unit environment. 2 Have a copy of hospital regulations available. 3 Explain that that there is no reason to be concerned. 4 Reassure the client that the staff is available if the client has questions.

1 Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. Explaining that that there is no reason to be concerned may be false reassurance, because no one can guarantee that there is no reason to be concerned. Reassuring the client that the staff is available to answer questions implies that staff members are available only if the client has specific questions.

A newly hired nurse during orientation is approached by a surveyor from the department of health, The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1 "Let me get my preceptor." 2 "Wash your hands before and after any client care." 3 "Clean all instruments and work surfaces with an approved disinfectant." 4 "Ensure proper disposal of all items contaminated with blood or body fluids."

2 The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of handwashing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be dispose

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: 1 Promoting analgesia and circulation 2 Numbing the nerves and dilating the blood vessels 3 Promoting circulation and reducing muscle spasms 4 Causing local vasoconstriction, preventing edema and muscle spasm

4 Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasm. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels.

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately? 1 Suction the tracheostomy. 2 Change the tracheostomy tube. 3 Readjust the tracheostomy tube and tighten the ties. 4 Perform a complete respiratory assessment.

1 Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem solving may require readjustment of the tracheostomy tube and ties or a physician changing the tracheostomy tube.

A plan of care for a client newly diagnosed with type 1 diabetes includes teaching how to self-administer insulin, adjust insulin dosage, select appropriate food on the prescribed diet, and test the serum for glucose. The client demonstrates achievement of these skills and is discharged five days following admission. What is the legal implication in this situation? 1 The nurse was functioning as a health teacher when providing the instructions. 2 A home health care nurse should have done the health teaching in the client's home. 3 Before discharge, family members also should have been taught how to administer insulin and perform other aspects of care. 4 Before implementation, the nurse should have the plan approved by all other members of the client's health care team. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

1 The Nurse Practice Act states that the nurse will do health teaching and administer nursing care supportive to life and well-being. The teaching was essential before discharge. The client is responsible for self-care. Health teaching is an independent nursing function.

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? 1 Primary nurse 2 Nurse clinician 3 Nurse coordinator 4 Clinical nurse specialist

1 The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or health care provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. A clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply. 1 Take the aspirin with meals or a snack. 2 Make an appointment with a dentist if bleeding gums develop. 3 Do not chew enteric-coated tablets. 4 Switch to Tylenol (acetaminophen) if tinnitus occurs. 5 Report persistent abdominal pain.

1,3,5 Acetylsalicylic acid (aspirin) is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Enteric-coated tablets must not be crushed or chewed. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner. Aspirin therapy may lead to GI bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1 Sodium 2 Potassium 3 Calcium 4 Calcitonin

2 A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water to move out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity, as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1 "I don't mind it." 2 "You seem upset." 3 "This is part of my job." 4 "Nurses get used to this."

2 The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it." or "Nurses get used to this." negates the client's feelings and presents a negative connotation.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.with anesthetic agents? 1 Colitis 2 Stomatitis 3 Paralytic ileus 4 Gastrocolic reflux

3 After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. Correct3 Encourage early mobility. 4 Elevate the knee gatch of the bed.

3 In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore, restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and also increase the risk for thrombophlebitis.

A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform? 1 Do not administer the vaccine until checking with the physician. 2 Do not administer the vaccine due to pregnancy contraindication. 3 Administer the usual dose of the vaccine. 4 Administer half the usual dose of the vaccine.

3 Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. There is no need to check with the physician prior to administration. The seasonal flu shot has been given safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies. Flu shots are not contraindicated; however, the nasal vaccine is. There is no indication that dosages should be altered.

A nurse adds 20 mEq of potassium chloride to the intravenous (IV) solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug? 1 Treat hyperpnea. 2 Prevent flaccid paralysis. 3 Replace excessive losses. Incorrect4 Treat cardiac dysrhythmias.

3 Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore, potassium, along with the replacement fluids, is needed. Potassium will not correct hyperpnea. Flaccid paralysis does not occur in diabetic ketoacidosis. Considering the relationship between insulin and potassium, treatment with KCl is prophylactic, preventing the development of dysrhythmias.

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the patient's emotional well-being and care. Visitors who have been in contact with the patient before and during hospitalization are a possible source of influenza for other patients, visitors, and staff.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply. 1 Diplopia 2 Dysphagia 3 Tachypnea 4 Bradycardia 5 Hypotension Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

3,5 Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.

A nurse is caring for a client that has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client's discharge? 1 Contact the client's health care provider to ask to substitute liquid form of medications for the pill form. 2 Teach the client and family members to crush the pills and administer them with applesauce. 3 Contact the client's health care provider to discuss use of transdermal medications for pain control. 4 Teach the client and family members about addiction that may occur as a result of regular opioid use.

3 The client will be discharged home with hospice and therefore there is no chance that dysphagia will be relieved by surgery or will improve by other measures. Considering that the client is approaching death and the client's condition is deteriorating, the transdermal route of administration of the pain medications is less invasive and provides comfort. The liquid form of pain medication or crushing the pills and administering them with applesauce is not possible because the client has dysphagia. The client is approaching the end of life and requires comfort measures; therefore opioid addiction is not a nursing concern for the dying client.