N524 EAQ #6 Fundamentals Of Nursing: Fundamental Skills

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? 1 Administer a mineral oil enema. 2 Offer 1 cup of fluid every hour. 3 Manually remove fecal impactions. 4 Offer a cup of prune juice.

4 Offer a cup of prune juice. ---------------------------------- Prune juice does not require a primary healthcare provider's order and helps to promote bowel movement because it contains sorbitol that increases water retention in feces. Administration of a mineral enema requires a prescription from a primary healthcare provider. Encouraging the client's fluid intake by offering 1 cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as prune juice. Removing impactions does not establish regular bowel patterns.

A nurse should employ which technique to maintain surgical asepsis? 1 Change the sterile field after sterile water is spilled on it. 2 Put on sterile gloves and then open a container of sterile saline. 3 Place a sterile dressing no more than half an inch from the edge of the sterile field. 4 Clean the surgical area with a circular motion, moving from the outer edge toward the center.

1 Change the sterile field after sterile water is spilled on it. ------------------------------- A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.

The nursing student accompanies a group of registered nurses in a campaign that promotes the participation of parents to get their children immunized. After the campaign's completion, the group prepares a report that counts the number of immunizations and compares it to last year's report. Which type of research does the nursing student think that the group is doing? 1 Evaluation research 2 Descriptive research 3 Experimental research 4 Correlational research

1 Evaluation research ------------------------- Evaluation research tests the effectiveness of a program, practice, or policy. It measures the outcomes of a campaign. Descriptive research measures the characteristics of persons, situations, or groups. For example, this study would measure the frequency of an occurrence of an event. Experimental research is a study where the investigator controls the study variable and randomly assigns the subjects to different conditions for the variable test. Correlational research explores the interrelationships among variables of interest; this study does not include any active intervention by the researcher.

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 Metabolic acidosis ---------------------------- A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis, not alkalosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the healthcare provider's writing. Who should the nurse ask for clarification of this prescription? 1 Nurse practitioner 2 House healthcare provider who is on call 3 Healthcare provider who wrote the prescription 4 Nurse manager familiar with the healthcare provider's writing

3 Healthcare provider who wrote the prescription ---------------------------------------------------- The healthcare provider who wrote the prescription should be called for clarification. The nurse is liable and responsible if the prescription is misinterpreted. Only the healthcare provider who wrote an undecipherable prescription can correctly clarify the prescription, not the nurse practitioner, house healthcare provider, or nurse manager.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? 1 Increase fluids. 2 Increase fiber in the diet. 3 Wash hands with soap and water. 4 Wash hands with an alcohol-based hand sanitizer.

3 Wash hands with soap and water. ------------------------------------- Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? 1 Suddenness of the change 2 Obviousness of the change 3 Extent of the change 4 Perception of the change

4 Perception of the change ----------------------------- It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

The nurse understands that the action of an antidiuretic hormone (ADH) is to do what? 1 Reduce blood volume 2 Decrease water loss in urine 3 Increase urine output 4 Initiate the thirst mechanism

2 Decrease water loss in urine ---------------------------------------- ADH is released by the posterior pituitary gland. It is mainly released in response to either a decrease in blood volume or an increased concentration of sodium or other substances in plasma. It acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1 "Moderate amount of drainage." 2 "No change in drainage since yesterday." 3 "A 10-mm-diameter area of drainage at 1900 hours." 4 "Drainage is doubled in size since last dressing change."

3 "A 10-mm-diameter area of drainage at 1900 hours." ------------------------------------------------------- A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? 1 Procedures for a client's benefit do not require a signed consent. 2 Clients who are aphasic are incapable of signing an informed consent. 3 A separate signed informed consent for routine treatments is unnecessary. 4 A specific intervention without a client's signed consent is an invasion of rights.

3 A separate signed informed consent for routine treatments is unnecessary. -------------------------------- This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

What is the priority nursing intervention for a client during the immediate postoperative period? 1 Monitoring vital signs 2 Observing for hemorrhage 3 Maintaining a patent airway 4 Recording the intake and output

3 Maintaining a patent airway ------------------------------- Maintenance of a patent airway is always the priority, because airway obstruction impedes breathing and may result in death. Monitoring vital signs, observing for hemorrhage, and recording the intake and output is important; however, a patent airway is the priority.

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply. 1 Assessing vital signs 2 Administering injections 3 Assessing wound drainage 4 Bringing equipment to the client's room 5 Transporting the client to a diagnostic test

4 Bringing equipment to the client's room 5 Transporting the client to a diagnostic test ------------------------------------------------ The nursing assistive personnel can bring equipment to a client's room and transport the client from one place to another. Because the client is on isolation precautions, the registered nurse should assess vital signs, administer injections, and assess wound drainage.