NR226 HESI study
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? 1 Respiratory rate 2 Amount of oxygen in the blood 3 Percentage of hemoglobin-carrying oxygen 4 Amount of carbon dioxide in the blood
3 The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not measure respiratory rate, nor does it interpret the amount of oxygen or carbon dioxide carried in the blood.
Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself? 1 Focusing 2 Clarifying 3 Paraphrasing 4 Summarizing
1 Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube
1 Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred, aspiration will result.
A client has excessive edema. Which is the most objective method a nurse can use to assess the extent of edema? 1 Weighing the client 2 Monitoring the intake and output 3 Performing the Trendelenburg test 4 Assessing the extent of pitting edema
1 One liter of fluid weighs approximately 2.2 pounds (1 kg); weight reflects subtle changes in fluid balance. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. The Trendelenburg test facilitates assessment of venous peripheral vascular disease, not the extent of edema. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client.
A client is experiencing stomatitis as a result of chemotherapy. Which action should the nurse take when caring for this client? 1 Provide frequent saline mouthwashes 2 Use karaya powder to decrease irritation 3 Increase fluid intake to compensate for accompanying diarrhea 4 Offer meticulous skin care of the abdomen with a gentle antiseptic
1 Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral mucosa.
A hospice nurse is caring for a dying client while several family members are in the room. When the client dies, the initial nursing intervention during the shock phase of a grief reaction is focused on what? 1 Staying with the individuals involved 2 Directing the individual's' activities at this time 3 Mobilizing the support systems of the individuals 4 Presenting the full reality of the loss to the individuals
1 Staying with the individuals involved provides support until the individuals' coping mechanisms and personal support systems can be mobilized. Directing the individuals' activities at this time is not the role of the nurse. The individuals, not the nurse, must mobilize their support systems. The individuals need time before the full reality of the loss can be accepted.
When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? 1 Decreased blood pressure 2 Increased oral temperature 3 Diminished peripheral pulses 4 Unequal bilateral breath sounds
1 The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.
The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply. 1 The client reports pain with movement. 2 The client has pain over the surgical area. 3 The client wants to know when he can go home. 4 The client rates the pain as 8 on a scale of 0 to 10. 5 The client has concerns about caring for the wound.
1,2,4 The nurse groups all information that contains a defining characteristic such as pain. The nurse clusters all assessments related to pain. The client reports pain with movement. The clinical criteria are observable and verifiable. The nurse learns that the pain is over the surgical area and not an underlying pain. The nurse verifies and measures the data by rating the pain as 8 on a scale of 0 to 10. The client wants to know when he can go home, but this assessment is not related to the pain. The client is also worried about caring for the wound, but this assessment will belong to a different cluster.
What are the priorities of a circulating nurse when a surgery is taking place? Select all that apply. 1 The nurse protects the client's privacy. 2 The nurse assesses the client's blood loss and urine. 3 The nurse monitors ventilation for nonintubated clients. 4 The nurse monitors the level of anesthesia provided to the client. 5 The nurse provides supplies and equipment on the basis of the surgical team's needs.
1,2,5 The nursing priority of the circulating nurse involves the protection of the client's privacy. The circulating nurse also is involved in making the assessment about the blood loss and urine of the client during the operative procedure. The nurse also provides supplies and equipment based on the needs of the surgical team. The anesthesiologist is responsible for monitoring the ventilation of nonintubated clients and the anesthesia provided to the client.
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. 1 Chronic stress 2 Severe anxiety 3 Generalized pain 4 Excessive caffeine 5 Chronic depression 6 Environmental noise/distractors
1,4,6 Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.
The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence
3 The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.
A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs? 1 Level 1 2 Level 2 3 Level 3 4 Level 4
2 A nurse who assists an older client in getting to the washroom is fulfilling the safety and security need, which is the second level of need according to Maslow's hierarchy of needs. The first level involves physiological needs such as air, water, and food. Belonging needs such as friendship, social relationships, and sexual love fall under the third level of need. The fourth level of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth and achievement.
An older widow with lung cancer is now in the terminal stage of her illness. Her family is puzzled by her mood changes and apparent anger at them. The nurse explains to the family that the client is doing what? 1 Trying to avoid her situation 2 Coping with her impending death 3 Attempting to reduce family dependence on her 4 Hurting because the family will not take her home to die
2 Anger is associated with one of the stages of dying; understanding the stages leading to the acceptance of death may help the family accept the client's moods and anger. Avoiding the situation reflects the stage of denial, when the reality of the situation is not being acknowledged; anger is not common in this stage. There are not enough data to indicate that the client is trying to reduce her family's dependence on her or that she wants to go home to die.
A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1 Using medication to induce elimination 2 Adhering to a definite time for attempted evacuations 3 Considering previous habits associated with defecation 4 Timing of elimination to take advantage of the gastrocolic reflex
2 Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.
A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the primary healthcare provider if the client does not void? 1 4 hours 2 8 hours 3 10 hours 4 12 hours
2 Clients should urinate 6 to 8 hours after catheter removal. Decreased bladder muscle tone results from the depressant effects of anesthesia and the handling of tissues and adjacent organs during surgery. Catheterization may be necessary to prevent overdistention of the bladder. Four hours may be too early to expect recovery from the depressant effects of anesthesia. Ten and 12 hours are too long to wait to call the primary health care provider. This length of time without voiding may result in overdistention of the bladder
A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant's hydration status? 1 Counting wet diapers 2 Obtaining daily weights 3 Measuring intake and output 4 Checking tissue turgor of the abdomen
2 Daily weighing provides an objective measurement, because a weight loss indicates a loss of fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid. Although a wet diaper count is an objective measure, it is necessary to weigh the diapers before and after the infant voids to estimate the amount of fluid loss. Intake can be measured accurately; however, output, especially with diarrhea, is difficult to measure. Tissue turgor is a subjective assessment, open to a variety of interpretations. Also, the site that should be assessed is over the sternum, not the abdomen.
When donning sterile gloves, how should the second glove be handled? 1 Grasp by cuff and place on remaining hand. 2 Place sterile glove under cuff, and slide hand in glove. 3 Grasp inside second glove and place on nondominant hand. 4 Don glove on nondominant hand first, then hold below waist and slide on.
2 Sterile gloves can only be handled by sterile equipment, or they are contaminated. The sterile glove that has been donned may touch under the cuff on the sterile surface as the nondominant hand is inserted. The sterile glove may not touch the inside of the glove. Donning a sterile glove and placing below the waist means contamination, as under the waist or in back is contaminated. Grasping by the cuff means the inside of the glove has been touched.
The nurse is inserting an indwelling urinary catheter into a male client. As the cather is inserted into the urethra, urine beings to flow into the tubing. What should the nurse do next? 1 Immediately twist the catheter, and then slowly inflate the baloon. 2 Insert the catheter 2.5 to 5 cm farther and then inflate the balloon 3 Insert the catheter until resistance is met and then inflate the baloon 4 Withdraw the catheter approximately 1 inch and then inflate the balloon.
2 The balloon is behind the opening at the catheter tip
When should the nurse use hypoallergenic tape or Montgomery straps as the best practice in postoperative skin care? 1 When conserving the client's energy 2 When protecting the fragile skin of the older client 3 When maintaining the psychosocial health of the older client 4 When improving perfusion to the wound to promote wound healing
2 The nurse should use hypoallergenic tape or Montgomery straps to protect the fragile skin of the older client. To conserve the client's energy, the nurse should allow the client to sleep in a darkened, quiet room. To maintain the psychosocial health of the older client, the nurse should allow the client liberal visitation by supportive persons. To improve perfusion to the wound to promote wound healing, the nurse should keep the client adequately hydrated to maintain cardiac output.
A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence
2,3,4,5 Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this affects the categories of mobility, activity, and friction on the Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing numbness or loss of sensation in the hands in feet; sensory perception is a category on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence
2,3,4,5 Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this affects the categories of mobility, activity, and friction on the Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing numbness or loss of sensation in the hands in feet; sensory perception is a category on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not used in the Braden Scale.
A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply. 1 Supple skin turgor 2 Rapid, thready pulse 3 Decreased hematocrit 4 Elevated specific gravity 5 Adventitious breath sounds
2,4 The pulse is rapid and thready because of the decreased blood volume associated with dehydration. The specific gravity of urine increases as the body reabsorbs water to correct the fluid deficit; as a result, the urine is concentrated. Skin turgor is decreased with evidence of tenting. The hematocrit is increased because of hemoconcentration. Adventitious breath sounds, such as crackles, occur with fluid volume excess, not with deficit.
A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. 1 The client will become capable of part-time employment. 2 The client will effectively express emotional and physical needs. 3 The client will demonstrate wellness reflective of physical potential. 4 The client will demonstrate an understanding of the mental health disorder. 5 The client will recognize the issues most important to managing this disorder.
2,4,5 Therapeutic communication facilitates the exchange of information between the nurse and the client that focuses on the client attaining health and wellness. This information can be directed toward the client's health needs, such as the effective expression of the client's physical and emotional needs, the understanding of the cause and prognosis of the current mental health problem, and the recognition of issues important to the management of the client's health issues. The client's ability to maintain part-time employment and the client's physical health potential are minimally affected by therapeutic communication.
An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? 1 Assess the client's mobility. 2 Monitor respirations and breathing effort. 3 Teach coughing and deep-breathing exercises. 4 Determine normal activity levels and note when the client tires
3 Older adults are at an increased risk for complications from both anesthesia and surgery. One of the age-related risk factors after surgery is a decrease in vital capacity. Teaching coughing and deep-breathing exercises may help in preventing pulmonary complications. Assessing the client's mobility may help an older client with a risk of musculoskeletal problems. Monitoring respirations and breathing effort is required for an older client with decreased blood oxygenation. An older adult with cardiovascular changes requires determination of normal activity levels and noting when the client tires.
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.
Which action of the nurse would be inappropriate in the context of critical thinking skills for making clinical decisions in nursing practice? 1 The nurse should observe changes in clients. 2 The nurse should identify new problems when they arise. 3 The nurse should follow direction in completing identified aspects of care. 4 The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan.
4 Clinical decision-making in nursing practice is based on critical thinking skills. The nurse uses knowledge and experience in critical thinking to plan and implement care plans for client care. The nurse would observe changes in clients to help detect problems early. These new problems, if identified early, may help in prompt treatment. Following the direction of the higher authority in completing the identified care aspects may not necessarily need knowledge and experience. Notifying the primary healthcare provider about a client's condition does not involve critical thinking skills.
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position
4 Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a healthcare provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, but will not prevent their accumulation.
The nurse is teaching a parent of a 2-year-old toddler how to administer ear drops. In what direction does the nurse teach the parent to gently pull the pinna? 1 Forward 2 Up and back 3 Straight back 4 Down and back
4 In children younger than 3 years of age the eustachian tube is shorter, wider, and more horizontal. Pulling the pinna down and back facilitates passage of fluid by way of gravity to the eardrum. Pulling the pinna forward does not help position the canal for passage of the drops to the eardrum. Pulling the pinna up and back is the technique used for administering ear drops to children older than 3 years of age and adults. Pulling the pinna straight back does not position the canal for passage of the drops to the eardrum.
Which pulmonary risk may be increased in a postoperative client due to anesthesia? 1 Rhonchi 2 Fremitus 3 Dyspnea 4 Atelectasis
4 Postoperative clients are at risk for atelectasis, which involves the collapse of the alveoli. This condition is caused by the effects of anesthesia. Rhonchi are continuous rumbling or snoring sounds caused by the obstruction of the larger airways. Fremitus is the vibration of the chest wall during vocalization. Dyspnea is shortness of breath; this condition is an after effect of atelectasis.
A client is having a tonic-clonic seizure. Which is a priority nursing action? 1 Elevating the head of the bed 2 Restraining the client's arms and legs 3 Placing a tongue blade in the client's mouth 4 Taking measures to prevent injury
4 Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.
A hospice nurse is caring for a dying client and his wife. What factor will be a major determinant in the mourning outcome for the wife? 1 Duration of the relationship shared by the couple 2 Age of the wife at the time of the husband's death 3 Health of the surviving spouse at the time of the death 4 Importance of the deceased person as a source of support
4 The more dependent the client was on the deceased for support, the more difficult the grieving process will be. Emotional and financial considerations are major factors. The duration of the couple's relationship and the age of the wife at the time of the man's death are not major influences on the mourning outcome. The health of the surviving spouse at the time of the death may or may not be a major factor in the mourning outcome; the spouse may be healthy and still be dependent on the partner.
The nurse is instructing a client with an eye disorder who is receiving prednisolone acetate eye drops regarding the precautions to be followed. Which statement made by the client indicates effective learning? 1 "I should check for bleeding in the eye." 2 "I should protect the drug from sunlight." 3 "I should refrain from wearing soft contact lenses." 4 "I should shake the bottle vigorously before I use the eye drops."
4 Topical steroids such as prednisolone acetate are suspensions and hence shaking is required to distribute the drug evenly in the solution before use. Using nonsteroidal anti inflammatory (NSAIDs) drugs may cause bleeding in the eyes because these drugs disrupt platelet aggregation. Topical antiviral drugs should be protected from sunlight. Using NSAIDs may interact with contact lens materials and increase the risk for infection.
A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply. 1 Drink a glass of wine. 2 Engage in mild exercise before bedtime. 3 Eat foods containing lysine. 4 Follow the same bedtime ritual each night. 5 Perform deep-breathing exercises
4,5 A bedtime ritual provides a familiar routine that promotes comfort and the self-fulfilling prophesy of sleep. Relaxation exercises slow body processes and reduces tension, both of which facilitate rest and promote sleep. People who drink alcohol may fall asleep more quickly but have depressed levels of rapid eye movement, less stage 4 sleep, and interruptions between sleep stages (sleep fragmentation). Physical exercise before bedtime has a stimulating rather than a relaxing effect. Lysine, an amino acid, maintains nitrogen equilibrium and promotes growth and development, but it does not influence sleep.
A client with CKD selects scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting high biologic value protein foods. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice to promote absorption. D. Encourage the client to attend classes on dietary management of CKD.
A. Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repain. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium and should not be encouraged (C). The client has made a good diet choice so (D) is not necessary.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it its much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
B Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. (B) This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D)
In developing a plan of care for a patient with dementia the nurse should remember that confusion in the elderly A. is to be expected and progresses with age B. Often follows relocation to new surroundings C. is a result of irreversible brain pathology D. can be prevented with adequate sleep
B Relocation (B) often results in confusion among elderly clients-moving is stressful for anyone. (A) is a stereotypical judgement. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the.... A. Arms B. Upper torso C. Head D. Feet
B The center of gravity for adults is the hips. However, at the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. The stopped posture results in the upper torso (B) becoming the center of gravity in older persons. Although (A) is a part, or extension of the upper torso, this is not the best and most complete answer.
A client who is 5'5 and weighs 200 lbs is scheduled for surgery the next day. What question is the most important for the nurse to include during the preoperative assessment. A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?
B Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid (D) died rather than the client's preference.
A female client with an NG tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the NG tube in the last two hours. What action should the nurse take first? A. Irrigate the NG with sterile normal saline B. Reposition the client on her side C. Advance the NG tube for an additional five centimeters. D. Administer an IV antiemetic prescribed for PRN use.
B. THe immediate priority is to determine of the tube is functioning correctly, which would then relieve the client's nausia. The least invasive intervention (B) should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D)
A hospitalised male client is receiving NG tube feedings via a small-bore tube and pump. He reports that he had a bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required. B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP. C. After clearing the tube with 30 mL of air, check the pH of fluid withdrawn from the tube. D. Inject 30 mL of air into the tube while auscultating for gurgling.
C Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward toward the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 mL of air) acidic or alkaline values is more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The ascultating method (D) has been found to be unreliable for small-bore feeding tubes.
A male client is being discharged with a scrip for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since at the time of discharge time-released capsules are not available, which dosing schedule should the RN advise the client to follow? A. 0900, 1300, 1700 B. 0800, 1600, 0000 C. Before breakfast, before lunch and before dinner D. With breakfast, with lunch, and with dinner
Theophylline should be administered on a regular around the clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around the clock dosing. Food may alter absorption of the medication. (D)
The primary health care provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply. 1 Tell a staff member to get the electrocardiogram machine. 2 Notify the x-ray department that a chest x-ray exam must be done stat. 3 Have a staff member notify the nursing supervisor of the change in client status. 4 Notify the healthcare provider of the change in the oxygen saturation to ask what to do. 5 Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen. 6 Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider.
This question makes no sense to me...... 1,2,3,6 A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray exam must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the healthcare provider. Notifying the healthcare provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.
