NUR 209 Final Exam Prep U

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question? "A heart rate of 160 beats/min is normal for a healthy infant." "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." "Every infant's heart rate is different, so you will need to discuss that with the health care provider."

"A heart rate of 160 beats/min is normal for a healthy infant." -Explanation: The average pulse rate of an infant ranges from 100 to 160 beats/min. There is no need to refer the parent to the health care provider for an answer

The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team? "You should remove your mask before you remove your gown." "Avoid touching the outside of your gown when removing it." "Whenever possible, remove your PPE outside the client's room." "it's best to let me assist you with removal of your gown."

"Avoid touching the outside of your gown when removing it." -Explanation: To prevent contamination, the outside of a gown should not be handled during removal. Gown removal should take place in the client's room, and the mask is not normally removed first. Assistance is not usually required with removal of a gown

A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause?

"Have you ever had an elevated blood sugar?" -Explanation: Polyuria means greater than normal urinary elimination. Untreated diabetes insipidus and hyperglycemia can greatly increase urine output. Ingestion of diuretics, caffeine, and alcohol also results in polyuria. Kidney disease is associated with a lack of urine output

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." -Explanation: The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter; this is accomplished by a secure dressing and taping the tubing so that it is not pulled

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? "You should not visit your friend if you have an infection of any kind because your friend may also get sick." "If you wash your hands before coming in contact with your friend you will prevent infection during your visit." "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." -Explanation: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. The other options do not control transmission of airborne or droplet infections. Hand hygiene is appropriate and should be encouraged but used alone it won't prevent the spread of an airborne or droplet infection

The nurse is assessing a client who is experiencing pain. The nurse notes the client is experiencing acute rather than chronic pain when the client makes which statement?

"The pain is really sharp in this one spot." -Explanation: Acute pain can be differentiated from chronic pain because it is specific and localized, whereas chronic pain tends to be nonspecific and generalized. Clients experiencing acute pain will indicate a recent onset whereas chronic pain has a remote onset. Acute pain is associated with sympathetic nervous system responses such as hypertension, tachycardia, restlessness, and anxiety, whereas chronic pain features the absence of autonomic nervous system responses and manifests with depression and irritability. Acute pain responds favorably when pain medication is administered. Chronic pain requires more frequent and higher doses of pain medication to elicit a positive response due to the threshold people build to the efficacy over time

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

"These brown spots are senile lentigines and are common when you get older." -Explanation: Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratosis, as these spots are raised in appearance. The spots are not likely cancer and do not need to be removed

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches." -Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued

The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. Use all options.

-Assist the client into a supine position. -Wait 3 to 10 minutes, then measure the client's blood pressure. -Assist the client to the sitting position with legs dangling. -Wait 1 to 3 minutes, then measure the client's blood pressure. -Assist the client to a standing position. -Wait 2 to 3 minutes, then measure the client's blood pressure

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

-Place the client in high Fowler's position. -Measure the intended length to insert the NG tube. -Lubricate the tube tip with water-soluble lubricant. -Direct the tube upward and backward along the floor of the nose. -Instruct the client to place the chin onto the chest. -Advance the tube while the client swallows.

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options.

-Provide instruction to the client. -Clean the area surrounding the urinary meatus with the provided cloth. -Void a small amount into toilet or bedpan. -Void into the provided collection device. -Secure the lid on the specimen container. -Submit collected specimen to the health care professional.

VS variations with old age

-Pulse rate decreases -RR decreases because chest expansion decreases -BP rises because elasticity/flexibility of the arteries decreases

A client has been diagnosed with anorexia nervosa. Which intervention(s) will the nurse employ during care? Select all that apply.

-Set a weight goal with the client. -Assess for depression. -Supervise client during meals and for 1 hour after. -Encourage liquid intake over solid foods. -Monitor for signs of food hoarding or disposing of food. -Provide small meals and snacks appropriately. -Explanation: Anorexia nervosa is an emotional disorder characterized by an obsessive desire to lose weight by refusing to eat. The nurse will assess nutritional status and set a weight goal with the client to determine if client is under- or overweight and nutritional needs. Clients with eating disorders often have accompanying depression with suicidal thoughts and should be monitored for safety. The nurse will supervise the client during meals and for at least 1 hour after eating to determine client's eating habits and prevent purging after meals. The nurse will encourage liquid intake over solid foods to eliminate the need to choose foods and provide hydration. Liquid intake is more easily digested. The nurse will provide small meals and snacks appropriately to prevent bloating and discomfort in clients following starvation and will encourage eating more appropriate portions.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

-Turn on the faucet and adjust force and temperature of the water. -Wet the hand and wrists. -Apply soap. -Wash the palms and backs of the hands for at least 20 seconds. -Pat the hands dry with a paper towel. -Turn the faucet off with a paper towel.

airborne precautions

-Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). -Place patient in a private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside, or monitored filtration if air is recirculated. Keep door closed and patient in room. -Wear a respirator when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases. -Transport patient out of room only when necessary and place a surgical mask on the patient if possible. -Consult CDC guidelines for additional prevention strategies for tuberculosis.

Principles of hand hygiene- soap and water, hand gel

1. Before touching a patient 2. Before clean/aseptic procedure 3. After body fluid exposure risk 4. After touching a patient 5. After touching patient surroundings

electric thermometers

2 secs-1 minute Blue prode is oral, red is rectal Advantages: ready for immediate use, rapid assessment, comfort, accuracy Disadvantages: Maintenance, cost

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?

30 to 60 breaths/min -Explanation: When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest

The nurse is caring for the following clients. Which client requires a negative air flow room? 21-year-old client with latent tuberculosis who is postoperative following repair of a femoral fracture 4-year-old client with Clostridioides difficile 81-year-old client with active tuberculosis and a productive cough 3-year-old client with influenza A and a productive cough

81-year-old client with active tuberculosis and a productive cough -Explanation: The client who requires a negative airflow room (airborne precautions) is the client with active tuberculosis. Active tuberculosis always requires a negative airflow room; latent tuberculosis does not. Clostridioides difficile requires contact precautions, not airborne precautions; therefore, negative airflow is not necessary. Influenza requires droplet precautions, not negative airflow

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A patient diagnosed with rubella A patient diagnosed with diphtheria A patient diagnosed with varicella A patient diagnosed with tuberculosis A patient diagnosed with MRSA An infant diagnosed with adenovirus infection

A patient diagnosed with rubella A patient diagnosed with diphtheria An infant diagnosed with adenovirus infection -Explanation: Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

A client is on bed rest and an enema has been prescribed. Which precaution(s) will be taken by the nurse to facilitate the client's comfort and participation? Select all that apply.

A reclining position on the left side, or Sims position, is recommended. The nurse will apply lubricant to the rectal tip before insertion of the enema. The client's buttocks should be raised when inserting into the rectum. The fluid should be instilled slowly, and pressure will be maintained until the tip is removed from the rectum.

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?

Administer the solution gradually over 5 to 10 minutes. -Explanation: Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.

A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. An increase in the pulse rate A decrease in body temperature A decrease in blood pressure An increase in respiratory depth An increase in respiratory rate An increase in body temperature

An increase in the pulse rate, An increase in respiratory rate -Explanation: The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth.

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area? Edge of the wound Area of active drainage Deep into the cavity Soiled dressing

Area of active drainage -Explanation: When obtaining a specimen for an aerobic wound culture, the nurse would obtain the specimen from deep in an area of active drainage. The specimen for an anaerobic culture is obtained from deep in the cavity to identify organisms that may grow where oxygen is not present. Cultures are not taken from the edges of the wound or from the soiled dressing

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

Assess for medication prescription for breakthrough pain. -Explanation: Breakthrough pain is a temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock. It can occur before the next dose of analgesic is due (end of dose pain). It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis." Therefore, the nurse should check for a prescription for breakthrough pain medication. Telling the client that he or she has to wait is not a therapeutic action by the nurse. Administering the next dose of pain medication is a violation of nursing practice and does not follow the standard of care. The nurse needs to assess for the therapeutic effects of the pain medication and not opioid addiction

The surgical nurse is caring for four clients. Which tasks can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. Changing the abdominal wound on a client with a recent colostomy. Attaining an admission weight for a client using a portable bed scale. Obtaining the initial set of vital signs on a client just back from surgery. Ambulating the client who is third day postoperative from right knee surgery. Documenting the urinary output of the client with a Foley catheter. Instructing the client on the proper use of an incentive spirometer.

Attaining an admission weight for a client using a portable bed scale, Ambulating the client who is third day postoperative from right knee surgery, Documenting the urinary output of the client with a Foley catheter. -Explanation: Using a portable bed scale for a weight, ambulating a stable client, and documenting urinary output are within the capability and scope of practice of UAP. The nurse should change the dressing, obtain initial vital signs, and teach clients. These tasks are not within the scope of practice of UAP, because they require assessing and educating the clients

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline. -Explanation: An NG tube that is not draining should normally be irrigated. Turning the suction off and on is less likely to be effective, and it may be unsafe to leave the suction turned off for half an hour. Digestive enzymes are not used on NG tubes that are used for suction. Removing the NG tube would be an action of last resort.

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information?

Auscultate for bowel sounds. -Explanation: An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention. Abdominal surgery places the client at risk for developing a paralytic ileus. The nurse would auscultate for bowel sounds, as absent bowel sounds 72 hours after abdominal surgery may signal that the client has developed a paralytic ileus. Measuring abdominal girth, asking about past bowel movements, and observing the dressing would not provide the needed information to determine if a paralytic ileus is occurring.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. -Explanation: The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Before removing the tube, discontinue suction and separate the tube from suction. -Explanation: When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding? Bradypnea is uncommon in a client with IICP. IICP most commonly results in tachypnea. Bradypnea is a response to IICP. This is a normal respiratory rate.

Bradypnea is a response to IICP. -Explanation: The normal respiratory rate for adults is 12 to 20 breaths/min. Bradypnea, a decrease in respiratory rate, characteristically occurs in some pathologic conditions. An increase in intracranial pressure depresses the respiratory center, resulting in slow breathing

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

chemical thermometers

Change color baked on temp, measure surface temp only

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order. -Explanation: The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after the order is confirmed.

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?

Check the client's ear canals for cerumen. -Explanation: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? Keep splashes on the sterile field to a minimum Cover the nose and mouth with gloved hands if a sneeze is imminent Use forceps soaked in a disinfectant Consider the outer 1 in of the sterile field as contaminated

Consider the outer 1 in of the sterile field as contaminated -Explanation: Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet?

Cranberry juice -Explanation: A clear liquid diet is composed only of clear fluids or foods that become fluid at body temperature. This includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, and commercially prepared clear liquid supplements. A clear liquid diet requires minimal digestion and leaves minimal residue. Low-fat milk, tomato soup, and juices with fruit pulp (orange and grapefruit) are considered full-liquid diet

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene? Decontaminate hands using an alcohol-based hand rub. Do not wash hands; apply clean gloves. Wash hands with soap and hot water. Wash hands with soap and water, followed by an alcohol-based hand rub

Decontaminate hands using an alcohol-based hand rub. -Explanation: Alcohol-based hand rubs can be used if hands are not visibly soiled. If the hands are visibly soiled, the nurse should wash hands with soap and hot water. The nurse should wash their hands. The nurse does not need to wash their hands AND use an alcohol-based hand rub

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

Decreased cardiac output -Explanation:- Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse. Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply. Decreased near vision Decreased facial hair Increased gag reflex Increased systolic and diastolic blood pressure Decreased tissue elasticity Increased mental confusion

Decreased near vision, Increased systolic and diastolic blood pressure, Decreased tissue elasticity -Explanation: Decreased near vision (presbyopia), increased systolic and diastolic blood pressure, and decreased tissue elasticity are normal signs of aging. Decreased facial hair, increased gag reflex, and increased mental confusion are not normal signs of aging

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? Change the sterile field, but reuse the sterile equipment. Proceed with the procedure since it was only touched by the client. Discard the sterile field and the supplies and start over. Call for help and ask for new supplies.

Discard the sterile field and the supplies and start over. -Explanation: The nurse's next appropriate action would be to discard the sterile field and the supplies and start over. The client touching the end of the sterile field contaminated the field and the items on the field. The nurse cannot reuse the sterile equipment because the items are no longer sterile. The nurse cannot proceed with the procedure since the items have been contaminated. Calling for help and asking for new supplies is not the best answer. The field has been contaminated also

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? No action is needed. Don another pair of sterile gloves. Complete a sentinel event report. Notify the primary care provider.

Don another pair of sterile gloves. -Explanation: If the nurse realizes that the sterile field is broken, the most appropriate response is to stop and don another pair of sterile gloves. A sentinel event has not occurred, and calling the PCP is unnecessary. Doing nothing and moving forward with foley insertion places the client at greater risk of infection and is not an appropriate action

A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?

Ensure the head of the bed is elevated. -Explanation: The head of the bed should be elevated before giving medications or performing a tube feeding. Following this, the placement of the tube should be checked, aspirate the gastric contents with a syringe, and then flush the tube with the ordered amount of water

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first? Provide a warm, quiet, dimly lit room Assess the cause of the client's wound Evaluate the blood pressure and pulse Interview to obtain the health history

Evaluate the blood pressure and pulse -Explanation: In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock

Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply.

Examples of those in the United States at risk for an inadequate nutritional intake include older adults who are socially isolated or living on fixed income, homeless people, children of economically deprived parents, pregnant adolescents, people with substance use problems, and clients with eating disorders. Children of middle-income parents and individuals who prefer to purchase food from local farmers are not necessarily at risk.

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? Follow-up measurements of blood pressure Immediate treatment by a health care provider No action, because the nurse considers this reading is due to anxiety A change in dietary intake

Follow-up measurements of blood pressure -Explanation: A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck.

The nurse is preparing to administer an enema to a client who is constipated. Upon assessment, the nurse notes painful distended veins on the exterior rectum. Which action will the nurse take next?

Generously lubricate the enema tube tip before proceeding. -Explanation: Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. Hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Hemorrhoids can tear due to the firm enema tip; therefore, the enema tip should be generously lubricated and administered with caution to avoid tearing. Continuing as usual is inappropriate due to the hemorrhoid finding. Nurses do not digitally stimulate a client to void. The decision to change the enema solution is a health care provider order; therefore, the nurse cannot perform this option without speaking with the provider first.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

Give the client a bath in tepid water. -Explanation: The body loses heat to the water through conduction during tepid baths. Applying a blanket would reduce radiant heat loss and would raise the client's temperature. Increasing the body's metabolic rate will result in an increase in temperature. Blowing warm air over the client will increase the temperature.

The nurse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearing. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, will include which instructions? Select all that apply.

Gradually increase activities as tolerated, Increased stress may interfere with recovery. Do not use the salt shaker at meals. -Explanation: Promoting health for older adults includes ensuring adequate nutrition (e.g., low-fat diet, other diet modifications); balancing calories and activities; planning exercise as a daily activity; and educating the client that illness is a physical and emotional stress and increases the risk for complications. Taking naps will interfere with sleep at night.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? The use of gloves eliminates the need for hand hygiene. The use of hand hygiene eliminates the need for gloves. Hand hygiene is needed after contact with objects near the client. Hand lotions should not be used after hand hygiene.

Hand hygiene is needed after contact with objects near the client. -Explanation: Hand hygiene must be performed when moving from a contaminated body site to a clean body site during client care and after contact with inanimate objects near the client. Using gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still be used after hand hygiene. Lotions may be used to prevent irritation

The spouse of a client with cancer asks why the client's breakthrough doses of morphine have recently needed to be higher and more frequent for the client to achieve pain relief? Which response by the nurse is appropriate?

Higher doses are needed because the client has developed a tolerance to the morphine. -Explanation: This client is likely developing drug tolerance, which occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief. This is not a pathologic finding and does not necessarily indicate physical dependence. Addiction is the fact or condition of being addicted to a particular substance, thing, or activity. Tolerance does not indicate addiction or a heightened risk for addiction. A drug interaction is a reaction between two (or more) drugs or between a drug and a food or beverage

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique? Hold sterile objects above waist level to prevent inadvertent contamination. Consider the outside of the sterile package to be sterile. Consider the outer 3-in. (8-cm) edge of a sterile field to be contaminated. Open sterile packages so that the first edge of the wrapper is directed toward the nurse.

Hold sterile objects above waist level to prevent inadvertent contamination. -Explanation: Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in. (2.5 cm) of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse

A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?

If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. -Explanation: If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?

If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. -Explanation: Warm water and gentle pressure should be used to unclog a tube. If a large amount of residue is accidentally aspirated, the health care provider should be notified. If the client is nauseated, the head of the bed should remain elevated and an antiemetic administered as prescribed. The tube should be in the stomach, not the esophagus

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. -Explanation: If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family?

Impaired Parenting associated with failure to provide stimuli for growth -Explanation: Based upon lack of stimuli (sensory deprivation), an appropriate nursing diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There is no information that states the child has impaired senses, sensory overload, or impaired skin integrity.

The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate? Place the client on calorie restriction. Administer a high-protein diet. Increase the client's fluid intake. Arrange for total parenteral nutrition (TPN).

Increase the client's fluid intake. -Explanation: Dehydration can cause increases in hematocrit, BUN, and creatinine. Calorie restriction, increased protein intake, and TPN are not indicated by these laboratory data

When assessing a client during the middle adult years, the nurse recognizes which of the following as a normal physical change?

Increased loss of calcium from the bones -Explanation: Some physical changes common during the middle adult years include increased fatigue, decreased cardiac output, increased loss of calcium from the bones, and decreased oil levels (resulting in dry skin).

The nurse is teaching a class about caloric intake. Which statement should the nurse use to describe why weight loss may occur when a client has an infection?

Infection increases the basal metabolic rate and causes more calories to be utilized. -Explanation: Dietary patterns should be adjusted to maintain a balance between caloric intake and energy expenditure. Basal metabolism is the amount of energy required to carry out involuntary activities at rest (e.g., breathing, circulating blood, maintaining body temperature). Men usually have a higher basal metabolic rate (BMR) than do women because of their proportionally greater muscle mass. Other factors, such as growth, infection, fever, stress, and extreme environmental temperatures, can increase BMR. Perspiration does not burn calories. Diarrhea can cause a lack of nutrients to be absorbed, but not all infections cause diarrhea. An increased respiratory rate is not known to increase BMR

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. -Explanation: To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first?

Inspect the area of itchy skin. -Explanation: Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply.

Irregular edges, Larger than 1/4 inch in diameter, Change in the mole -Explanation: The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client? -It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. -It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results. -This has no impact on BP readings and he should continue doing what he has been doing. -This is unusual and he should be seen by the physician as soon as possible.

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. -Explanation: It has been found that most people have differences in BP between arms. For accurate results, the initial reading should be obtained from both arms and where there is a consistent interarm difference, the client should use the arm that gives the highest reading. However, there will be situations when the arm with the highest reading may not be used doe to surgery, IV lines, or other issues. The nurse should continue to monitor the client to ensure the best reading is obtained

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds. -Explanation: The apex of the heart is found by palpating between the fifth and sixth ribs, then moving the stethoscope to the left midclavicular line. The apical rate is typically assessed for 1 minute. Each "lub-dub" sound counts as one beat

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment?

Monitoring the characteristics of the urinary output -Explanation: The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the client should exhibit urine that is clear, without evidence of clots or debris. The client will have no PVR during therapy. Palpation of the bladder region and calculation of a particular outflow rate do not determine the success or failure of therapy

pulse rates throughout age

Newborn (80-180 Teen (50-90) Adult (60-100) Older adults 60-100

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply.

Nurses need to know about medications that may produce varied responses in patients from different ethnic groups. The patient's expectations of the medication may affect the response to the medication, for example, when a placebo is given and a patient has a therapeutic effect. The patient's environment may also influence the patient's response to medications, for example, sensory deprivation and overload may affect drug responses. Circadian rhythms and cycles may also influence drug action. The liver is the primary organ for drug breakdown, thus pathologic conditions that involve the liver may slow metabolism and alter the dosage of the drug needed to reach a therapeutic level. The presence of food in the stomach can delay the absorption of orally administered medications. Alternately, some medications should be given with food to prevent gastric irritation, and the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhanced absorption if taken with certain foods.

The nurse is conducting a pain assessment with an older adult client. The nurse notices that the client grimaces when the nurse asks the client to lean forward. The client, however, rates pain as 3 out of 10 on the numerical pain rating scale. The nurse recognizes that the client may be reporting pain inaccurately for which reason(s)? Select all that apply.

Older adults may not report pain for several reasons, such as not wanting to be perceived as a nuisance or a complainer, believing that pain is expected with aging or is an indicator of weakness, fearing addiction to pain medication, or misperceiving that nothing can be done to alleviate the pain. By recognizing and exploring possible reasons for the incongruence between the objective and subjective assessment data, the nurse can improve the quality of the client's pain management. The nurse will not assume that the client has a high tolerance for pain. Because the client is showing non-verbal signs of significant pain (facial grimace), the nurse must probe further to determine the source of the client's inaccurate reporting of the pain. Doing so can lead to further education about pain management and better client outcomes.

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use?

Palpate one artery at a time. -Explanation: To palpate the carotid arteries, the nurse would lightly press on one side of the neck at a time. Never attempt to palpate both carotid arteries at the same time as bilateral palpation could result in reduced cerebral blood. It is not necessary to count the carotid rate

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? Perform hand hygiene Don a new pair of gloves to dispose of materials Wrap all used materials together and discard in biohazard container Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

Perform hand hygiene -Explanation: Inverting the gloves into each other encloses the soiled surface and blocks a potential exit route for microorganisms. After removing gloves, the next step would be to perform hand hygiene which should be conducted before touching the loved one. Used materials are not always disposed of in biohazard containers. Donning new gloves should not be necessary as materials should have already been disposed of prior to removing the gloves. Lotions that work in conjunction with soaps and lotions should be used when applying lotion after performing hand hygiene but this is not the next step

The nurse prepares for a sterile procedure. Of those listed, what action does the nurse perform first? Put on personal protective equipment, if required. Perform hand hygiene. Check that the packaged kit is dry and unopened. Set up a work area at waist level.

Perform hand hygiene. -Explanation: When preparing for a sterile procedure, the nurse will perform hand hygiene followed by any personal protection equipment, if required. Next, the nurse confirm the client's identity with the order and explains the procedure to the client. Then, the nurse the will check that the sterile package or kit is dry and unopened as well as the expiration date. Next, the nurse will set up a work area at waist level or higher followed by opening the outside package and remove the kit

The nurse is planning an educational event for a group of senior citizens on the topic of the normal signs of aging. Which topic(s) should the nurse include about healthy activities a person can engage in to prevent the problems associated with aging? Select all that apply.

Physiologic changes and an increased incidence of chronic illnesses place older adults at greater risk for declines in health and quality of life. Health promotion strategies (good lifestyle habits) and health maintenance (disease prevention and treatment) afford even the oldest adult an advantage in maintaining optimal health. Exercise, not necessarily vigorous aerobic, is an example of a good lifestyle habit. Taking all medications as prescribed is an example of health maintenance. Vitamins and supplements should only be taken under the supervision of a health care provider. Maintaining friends and social activities have been noted as improving overall health in older adults as it prevents loneliness and "hibernation" type activities.

The nurse is preparing to administer a client's ordered tube feeding and the client aspirates gastric contents. Testing of the pH yields a result of 5.3. What is the nurse's most appropriate action?

Proceed with the feeding as ordered. -Explanation: The pH of gastric contents is acidic (less than 5.5); a pH of 5.3 thus constitutes an expected finding. There is no need to delay the feeding or reconfirm tube placement.

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. Providing a bed bath for a patient Visibly soiled hands after changing the bedding of a patient Removing gloves when patient care is completed Inserting a urinary catheter for a female patient Assisting with a surgical placement of a cardiac stent Removing old magazines from a patient's table

Providing a bed bath for a patient, Removing gloves when patient care is completed, Inserting a urinary catheter for a female patient, Removing old magazines from a patient's table -Explanation: It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. Keep in mind that handrubs are not appropriate for use with C. difficile infection.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position. -Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

The nurse is engaged in collecting a urine specimen for a routine urinalysis from a client with an indwelling catheter. What nursing action has the greatest impact on the accuracy of the testing results?

Selecting this particular specimen port site -Explanation: When it is necessary to collect a urine specimen from a client with an indwelling catheter, the specimen should be obtained from using the special port for specimens. This practice assures aspiration of fresh urine and helps assure result accuracy. A routine urinalysis requires at least 10 ml of urine; assuring a sufficient quantity of urine. Wearing gloves protects the nurse from any contact with the specimen. A client should be placed in position that supports comfort and modesty. While all actions are accurate, appropriately accessing the specimen port has the greatest impact on the accuracy of the urinalysis.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. -Explanation: The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

An older adult client is admitted into the hospital due to pneumonia. Which transmission-based precautions should the nurse initiate?

Standard -Explanation: The nurse should implement standard precautions, as these precautions are appropriate for all hospitalized clients. There is no indication that additional precautions such as airborne, droplet, or contact precautions are needed at this time

The nurse is caring for a client who developed a urinary tract infection while hospitalized. What intervention(s) will the nurse initiate to care for this health care-associated infection? Select all that apply. Standard precautions such as gloves and hand hygiene Wear mask, eye protection, and gown for all client contact Move client to an airborne infection isolation room Move client to a private room for safety precautions Transmission-based precautions including proper disinfecting of equipment

Standard precautions such as gloves and hand hygiene, Move client to a private room for safety precautions, Transmission-based precautions including proper disinfecting of equipment -Explanation: Moving the client to a private room would reduce the likelihood that a roommate may get the infection due to cross-contamination or contact. An airborne infection isolation room is not necessary because the infection is not due to an airborne organism. Standard precautions would be initiated as well as transmission-based precautions as set forth by the Centers for Disease Control and Prevention. Mask and eye protection is only necessary for splash precautions.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily. -Explanation: If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure. -Explanation: When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response

A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?

The client makes noises when he breathes. -Explanation: Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome

The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching?

The client sits in the chair with feet flat on the floor and arm below the level of the heart. -Explanation: The client behavior that indicates the need for additional teaching is client sitting in the chair with feet flat on the floor and arm below the level of the heart. Taking a blood pressure with the arm in that position can give a falsely high reading. The client placing the blood pressure on the upper arm just above the antecubital space, the client sitting in the chair with feet flat on the floor and arm supported at the level of the heart, and the client using a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm all indicated correct methodology for self-measuring blood pressure and thus require no need for further teaching

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? Preferred site for temperature assessment The client's nutritional status The client's most recent temperature The client's wellness goals

The client's most recent temperature -Explanation: Prior to assessment, the nurse should note the client's baseline or previous temperature measurements. Assessment results must always be considered in light of client-specific baselines. The client's wellness goals are important, but these are not directly relevant to temperature assessment. Similarly, nutritional status has a minimal bearing on temperature assessment. The client's preferred site for assessment is important, but the nurse ultimately determines the most appropriate site based on nursing knowledge

A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply.

The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? The new nurse touches 1.5 in (4 cm) from the outer edges. The sterile field is set up at waist level. Direct visualization of the sterile field is maintained. The top flap of the package is opened away from the new nurse's body.

The new nurse touches 1.5 in (4 cm) from the outer edges. -Explanation: Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body

A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply. The nurse carries soiled items away from the body. The nurse places soiled bed linen on the floor. The nurse moves soiled equipment away from the body when cleaning it. The nurse opens a window and dusts the room in the direction of the window. The nurse cleans least soiled areas first and then moves to more soiled ones. The nurse pours discarded liquids into a basin then pours them into the drain.

The nurse carries soiled items away from the body, The nurse moves soiled equipment away from the body when cleaning it, The nurse cleans least soiled areas first and then moves to more soiled ones. -Explanation: The nurse would be following medical asepsis when the nurse carries soiled items away from the body, moves soiled equipment away from the body when cleaning it, and cleans least soiled areas first—then moves to more soiled areas. The nurse would not place soiled bed linen on the floor. The nurse would not open a window and dust the room in the direction of the window. The nurse would not pour discarded liquids into a basin before pouring them into the drain

An operating room nurse is putting on sterile gloves to assist with client surgery. Which action(s) is performed correctly in this procedure? Select all that apply. The nurse places the sterile gloves on a clean dry surface at or below waist level. The nurse opens the outside wrapper by carefully peeling the top layer back. The nurse places the inner package on the work surface with the side labeled "cuff end" furthest from body. The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove. The nurse touches only the inner surface of the package and the gloves.

The nurse opens the outside wrapper by carefully peeling the top layer back, The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides, The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove, The nurse touches only the inner surface of the package and the gloves -Explanation: There are several actions that the operating room nurse will perform when putting on sterile gloves. First, the nurse will open the outside wrapper by carefully peeling the top layer back. The nurse will carefully open the inner package by folding open the top flap, then the bottom and sides. The nurse will lift and hold the glove up and off the inner package with fingers down and carefully insert the hand "palm up" into the glove. The nurse will touch only the inner surface of the package and the gloves. The nurse would work at a surface level at or above the waist. The nurse would place the inner package labeled "cuff end" nearest to the body. The nurse touches only the outer surface of the inner package

A nurse maintaining continuous bladder irrigation on a client notes that hourly drainage is less than amount of irrigation being given. Which interventions would be appropriate in this situation? Select all that apply.

The nurse should palpate for bladder distention; if the client is lying supine, roll the client onto his or her side to help increase the amount of drainage. The nurse should also check to make sure that the tubing is not kinked and, if return flow remains decreased, notify the health care provider. Irrigation would likely be attempted before removal. The balloon is not deflated and reinflated to resolve this problem.

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply.

The nurse will provide instructions about the medication prescribed for pain relief. This medication is an opioid, and extra precautions are required. The client is not to drive a vehicle while taking an opioid due to slowed reflexes and decreased cognitive thinking. The client is not to breast-feed her infant without checking with her primary care provider. The opioid may be absorbed into the breast milk and fed to the infant, which may adversely affect the infant. The client is to keep a diary about her pain experiences, which includes level of pain and time the medication was taken. This provides a more accurate documentation of the pain experience and prevents overdosage from taking the medication too frequently. The client is not to drink alcohol. Alcohol will depress the central nervous system when taken with an opioid and may lead to respiratory failure. The client may smoke, but someone will need to be present (for safety reasons) since the client may fall asleep due to the opioid. It does not matter whether it is day or night. The medication is not better absorbed when taken on an empty stomach. The client takes the pain medication with food, since nausea is a frequent side effect when the opioid is taken on an empty stomach.

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? The nurse puts on PPE after entering the patient room The nurse works from "clean" areas to "dirty" areas during bath The nurse personalizes the care by substituting glasses for goggles The nurse removes PPE after the bath to talk with the patient in the room

The nurse works from "clean" areas to "dirty" areas during bath

A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?

To rest the gastrointestinal tract and promote healing -Explanation: Withholding food may be indicated in the following situations: to rest the gastrointestinal tract to promote healing, clear the gastrointestinal tract of contents before surgery or diagnostic procedures, prevent aspiration during surgery or in high-risk clients, give normal intestinal motility time to return, treat severe vomiting or diarrhea, and to treat medical problems, such as bowel obstruction or acute inflammation of the gastrointestinal tract. Withholding food does not cause gas to accumulate or increase the amount of mucus in the bowel

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? Not to worry and to take double the dose of BP medication To call her health care provider To take the medication that she missed and retake her BP To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. -Explanation: HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is not 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted?

UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan. -Explanation: It is important to place the bedpan in the proper position to prevent spills onto the bed, ensure client comfort, and prevent injury to the skin from a misplaced bedpan. Therefore, the UAP should position the bedpan so the client's buttocks rest on the rounded shelf of the regular bedpan. Applying powder to the rim of the bedpan helps keep the bedpan from sticking to the client's skin and makes it easier to remove, unless it is contraindicated. The nurse uses less energy when placing the hand closest to the client palm up, under the lower back, and assisting with client lifting. A waterproof pad protects the bed from bedpan spillage.

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? Remove gown, goggles, mask, gloves, and exit the room Remove gloves, perform hand hygiene, then remove gown, mask, and goggles Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene Remove goggles, mask, gloves, and gown, and perform hand hygiene

Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene -Explanation: If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. -Explanation: The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 30 minutes before measuring the oral temperature -Explanation: The nurse should wait for 15 to 30 minutes and then measure the oral temperature of the client since hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation, not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site.

A nurse is assessing clients in the emergency department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods? Select all that apply.

When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. When assessing rectal temperature with an electronic thermometer, lubricate about 1 in (2.5 cm) of the probe with a water-soluble lubricant. When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard. -Explanation: Placing the probe beneath the client's tongue in the posterior sublingual pocket when taking an oral temperature allows the probe to be in contact with blood vessels lying close to the surface, providing a more accurate reading. Lubricating approximately 1 in (2.5 cm) of the probe when assessing a rectal thermometer reduces friction and facilitates insertion, minimizing the risk of irritation or injury to the rectal mucous membranes. The beeping sound of the electronic thermometer indicates that the measurement is complete. A new probe is used for every client when using a tympanic thermometer, which prevents the need to wipe the probe with alcohol prior to inserting the probe into the client's ear. Chemical dot thermometers are kept in place for 3 minutes when taking an axillary temperature. Axillary temperatures are usually about 1°F (0.5°C) lower than the oral temperature and rectal temperatures are usually about 1°F (0.5°C) higher than the oral temperature

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? After completing a wound dressing Before direct contact with clients After direct contact with clients When hands are visibly soiled

When hands are visibly soiled -Explanation: Alcohol-based hand rubs can be effective for decontaminating a health care worker's hands before and after direct contact with clients and after completion of a wound dressing, except when the health care worker's hands are visibly soiled

The health care provider tells the nurse that the desired body temperature for the client is 99.8°F (37.7°C). When does the nurse turn off the blanket?

When the client's temperature reaches 100.8°F (38.22°C). -Explanation: The blanket is turned off 1 degree above reaching the desired temperature because the body will continue to cool further, and it is desired to avoid hypothermia. The desired temperature is 99.8°F (37.7°C), so the blanket is turned off when the client's temperature is 100.8°F (38.2°C). The client who experiences hyperthermia may have nausea, vomiting, and dizziness due to the elevated temperature, but this is not an indication to discontinue therapy. Therapy is not discontinued secondary to feeling cold or uncomfortable, but it is discontinued if the client shivers, hyperventilates, or demonstrates other signs of overcooling

Which client would the nurse consider at risk for low blood pressure?

a client with low blood volume -Explanation: Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity of the arteriole walls would potentially cause increased blood pressure. A strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur. -Explanation: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? an 80-year-old woman a 2-year-old toddler a 12-year-old girl an 18-month-old infant

an 80-year-old woman -Explanation: Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection. A neonate is defined as a child less than 4 weeks of age. An adolescent is a child aged 9 to 12 years. A toddler is a child who is 12 to 36 months or 1 to 3 years of age

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? -an older adult client with a history of heart failure -a school-age child who is current with immunizations -an adolescent who has a right radial fracture -a middle-aged adult who takes prescribed medication to control blood pressure

an older adult client with a history of heart failure -Explanation: Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control blood pressure could develop an infection, but these clients are not at the highest risk

A nurse is caring for a client who had an appendectomy earlier in the day. The client now has bowel sounds and is passing flatus. Which food is appropriate for the nurse to serve to the client at this time?

apple juice -Explanation: A postoperative client whose bowel sounds return and is passing flatus is ready to begin a diet. The first diet offered is a clear liquid diet. Apple juice is a clear liquid because it can be seen through. Sherbet and Ensure would belong on a full liquid diet. Chopped fruit is a mechanically altered diet and is typically used when a client has chewing or swallowing difficulty

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?

ask the client to demonstrate self-blood pressure assessment -Explanation: While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback. -Explanation: Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief

Which pulse site is generally used in emergency situations?

carotid -Explanation: The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?

circumoral cyanosis when the client is at rest -Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema -Explanation: The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?

cloudy, foul odor -Explanation: The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine. Urine is normally light yellow and clear. Dark amber urine that is strongly aromatic could indicate dehydration, but would not create the symptoms noted.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse. -Explanation: Certain cardiac medications, such as digoxin, decrease the heart rate

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

eave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. -Explanation: Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response? -encourage the colleague to remove the glove by grasping the cuff -teach the colleague why the gloves should be removed outside the room -maintain a distance of at least 5 ft (1.5 m) from the colleague -take no action at this time

encourage the colleague to remove the glove by grasping the cuff -Explanation: The colleague should grasp the outside of one glove with the opposite gloved hand and peel the glove off, turning it inside out while peeling it off. The glove should not be pulled by the fingers, because this is unlikely to remove the glove and it may snap back. Personal protective equipment should normally be removed while inside the room, and there is no need to maintain a wide distance from the colleague.

Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line

handwashing after removing gloves -Explanation: Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

has manicured nails that are 1-in. (2.5-cm) long -Explanation: Fingernails should be less than ¼-in. (0.625-cm) long, as this reduces the reservoir for flora to accumulate and decreases the chance of tearing or puncturing gloves. Washing hands for 15 seconds is appropriate. Both the hands and wrists should be wetted. Allowing the hands to drain lower than the wrist promotes gravity drainage

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?

intermittent urethral catheter -Explanation: An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? into a private room with a client with pneumonia with a client with a myocardial infarction with another client with a draining wound

into a private room -Explanation: The client with confusion and a draining wound would, as would other clients on the unit, benefit most from a private room. The client cannot be expected to assist in maintaining appropriate hygiene or environmental control, so placement with another client who has a susceptible condition is not appropriate

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs?

large-volume cleansing enema with hypotonic solution -Explanation: Large-volume cleansing enemas are known as hypotonic or isotonic, depending on the solution used. Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying. Oil-retention enemas: lubricate the stool and intestinal mucosa, making defecation easier

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

noncommunicable disease -Explanation: A noncommunicable disease is caused by food or environmental toxin. Infectious disease, communicable disease, and contagious disease do not describe an illness that is contracted after eating food

meds that suppress respiratory rate

opiates and sedativesm general anesthetics

The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection? -perform meticulous hand hygiene -only accept clients who are not immune compromised and perform meticulous hand hygiene -perform meticulous hand hygiene and don a new mask with each client encounter -wear a mask and don gloves with each client encounter until symptoms are completely gone.

perform meticulous hand hygiene and don a new mask with each client encounter -Explanation: The nurse with a mild upper respiratory infection should don a new mask and practice meticulous hand hygiene with each encounter with a client. Hand hygiene alone will not control transmission of the infection. All clients are at risk for infection, not just those who are immune compromised. The window for being contagious varies dependent on the microorganism. The absence of a fever is not always an indication that the microorganisms can't be transmitted. Gloves are not specifically needed if hand washing procedures are followed with each contact

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds -Explanation: Skin turgor response that is greater than 3 seconds, especially in an older adult clients, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. Other assessment findings are normal

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? the client who is 48-hours postsurgical procedure the client admitted with a rash who reports recent exposure to measles the client admitted with diarrhea who tested positive for Escherichia coli (E. coli) the client placed in contact isolation who was admitted with a draining abdominal wound

the client who is 48-hours postsurgical procedure -Explanation: Medical asepsis, also called clean technique, are practices that confine and reduce the number of microorganisms. To minimize the spread of infection between clients, the nurse should see clients from the "clean" to "dirty." The nurse should see the client who has no signs of infection first. Among these clients, the nurse should begin with the client who is postoperative, then see the other clients who have symptoms of infections

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will:

urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." -Explanation: The client accurately details the steps of the procedure except the nurse needs to further instruct the client that the client needs to void a small amount of urine into the toilet and then stop

Which is not appropriate regarding the use of gowns as PPE? use of paper or cloth gowns donning a gown when splashing use of one gown per person per shift use of a new gown each time the nurse enters the room

use of one gown per person per shift -Explanation: A new gown should be used by the nurse each time the nurse enters the client's room

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse? wash the area with soap and water fill out a risk management form find out who left the scalpel blade on the procedure tray go to employee health for testing

wash the area with soap and water -Explanation: The first action by the nurse should be to wash the hands gently with soap and water to reduce exposure of blood or pathogens to the wound. Filling out a risk management form is required but should be done after first aid care is performed. Finding out who left the blade on the tray is not relevant at this time, but further education for the unit may be required at a later time. Going to employee health is the step that will be taken after immediate first aid

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding requires immediate action by the nurse? erythema at sting site heart rate of 100 beats/min wheezing on auscultation crying with burning pain

wheezing on auscultation -Explanation: Wheezing is an abnormal breath sound that is commonly seen with allergic reactions. Signs of allergic reaction (anaphylaxis) to bee stings are potentially life-threatening and require immediate treatment. Erythema, or redness of the skin, is expected at the sting site. A preschool-aged child has a higher pulse rate (ranging from 80 to 120 beats/min) than an adult. Heart rate also increases when a child is crying. Burning pain is expected after multiple bee stings

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?

apical -Explanation: The apical pulse is assessed when a client is being given medications that alter heart rate and rhythm.

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? "I will always wash my hands thoroughly and often." "It is important to refrain from recapping needles." "Masks, gloves, and gowns should be used to protect from infectious agents." "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

"Wearing an N95 respirator is critical when I care for clients in droplet precautions." -Explanation: N95 respirators are used when caring for clients in airborne precautions; therefore this statement requires further teaching. The other statements reflect that teaching has been effective.

what affects blood pressure

- blood volume - stroke volume - total peripheral resistance - heart rate > increase in any of these will increase blood pressure -Women tend to have lower than men -Race (AA men and women have higher, more hypertension) -oral contraceptives cause mild increase in blood pressure in many women

temporal artery thermometers

-Calculates in relation to room temperature to get approximate core temp -Advantages: more accurate than tympanic and oral, helpful in children -Disadvantages: expensive

MRSA (Methicillin Resistant Staphylococcal Aureus)

-Common in skin and would infections -Treated with aggressive drugs

tympanic thermometers

-Great for children Advatages: quick (2-3 secs), non invasive, easy, low risk of microoragnism exposure, not affected by eating/drinking, smoking -Disadvantages: variable accuracy, dependent on skill -Pull pinna down for patients under the age of 3 -up and back for adults

what affects pulse

-Decrease in blood pressure can decrease pulse -Elevated temperture can increase pulse -Hypovolemia (dehydration) (may have low pulse amplitude cuz not a lot of pressure on arteires due to low fluid)

Means of disease transmission

-Direct transmission (E. coli on lettuce, on food, kissing, touching, sexual contact.) -Indirect transmission (Inanimate objects that have organisms: on doorknobs and can live for minutes to days) -Airborne transmission

Laboratory data for infection

-Elevated WBC count (normal is 5-10,000), Increased white cells in the WBC differential -Erythrocyte sedimentation rate (ESR) -Urine, blood, sputum, or draingage cultures

adding a sterile drape

-For protection when positioning, fold the upper edges of the drape over the sterile-gloved hands -When sterile gloves are not worn, the nurse can touch only the outer 1 inch (2.5 cm) of the drape. -Use caution when gently shaking the drape open so as not to touch one's clothing or an unsterile object Hold the drape by the 1-inch upper edge and position the drape over the desired area. Do not reach over the drape because this would contaminate the sterile area.

Nursing interventions for alterations in temperature

-If fever, look at WBCs, hematocrit, -Provide adequate nutrition (they need more calories to fight it off), monitor their fluids because they lose a lot, Tepid (cool) bath -Assess skin -Decrease activity -Provide oral hygienc -Measure I&O (intake and out of fluid), they may get dehydrated when they lose fluid -Adminsiter antipyretics -Provide dry clothes and bed linen -Keep client comfortable

Correct procedures and contraindications for VS assessment

-If people have had surgeries -BP contraindications: Shoulder, arm, hand is injured or diseased, Cast or bulky bandage on limb, Lymph nodes have been removed from that side (mastectomy), Intravenous infusion in the limb, Arteriovenous fistula or graft in the limb

Stages of infection

-Incubation: While the organism is beginning to invade the body, before symptoms occur (a day up to 21 days) -Podromal: low grade fever, vague symptoms -Acute Stage of Illness: Symptoms become visible -Convalescent: Recovery period (antibodies, bone marrow produces WBCs)

Chain of Infection cycle

-Infectious agent (bacteria, virus, fungi, parasite), -Reservoir (people, animals, soil, food, water), -Portal of exit from reservoir (coughing/sneezing, bodily secretions, feces), -Means of transmission (direct contact, indirect contact, vectors) -Portals of entry (mouth, nose, eyes, cuts in skin), susceptible host (elderly, infants, immunocompromised (anyone) -Infectious agent (the microorganism: germ, bug, common infections like colds, flu and stomach bugs) -Colonization: When an organism resides in the person's body but there is no linical signs of infection

factors affecting risk of infection

-Integrity of skin and mucous membranes, which protect the body against microbial invasion -pH levels of the gastrointestinal and genitourinary tracts, as well as the skin, which help to ward off microbial invasionIntegrity and number of the body's white blood cells, which provide resistance to certain pathogens -Age, sex, race, and heredity, which influence susceptibility-neonates and older adults appear to be more vulnerable to infection -Immunizations, natural or acquired, which act to resist infection -Level of fatigue, nutritional and general health status, the presence of pre-existing illnesses, previous or current treatments, and certain medications, which play a part in the susceptibility of a potential host -Stress level, which if increased may adversely affect the body's normal defense mechanisms -Use of invasive or indwelling medical devices, which provide exposure to and entry for more potential sources of disease-producing organisms, particularly in a patient whose defenses are already weakened by disease

Doppler ultrasound/stethoscope

-Listen with doppler ultrasound sthosescope if can not be palpated -Used for difficult to palpate pulses: Cuz of venous insufficiency, Trauma, Verification post procedure

Rectal temperatures

-Most accurate core temp Invasive -Commonly used for infants, confused adults, clients with respiratory problems, clients with recent history of oral surgery -Disadvantages: inconvenient -Rectal temperature assessment can be embarrassing for the client, so provision of privacy is a priority. The client should be positioned on the side in Sims position to help facilitate probe insertion. The probe should be inserted 1 to 1.5 in (2.5 to 3.75 cm) in an adult client. The probe should only remain in the rectum until the electronic unit emits an audible sound indicating that the temperature assessment is complete

In which order should the following steps for putting the first hand into a sterile glove be performed?

-Place the sterile glove package on a clean, dry surface at or above your waist. -Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it. -Place the inner package on the work surface with the side labeled "cuff end" closest to the body. -Carefully open the inner package. Fold open the top flap, then the bottom and sides. -With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. -Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. -Carefully insert dominant hand palm up into the glove and pull it on.

Oral temperature

-Quickly reflects changing body temp, most accessible site, easily influenced -Contraindicated in infants and confused geriatric clients

Infection risk in older adult

-Skin infections: Loss of elasticity, Increased dryness, Thinning of epidermis, Slowing of cell replacement, Decreased vascular supply -UTI: Incomplete emptying of bladder, Decreased sphincter control, Bladder-outlet obstruction due to enlarged prostate gland, Pelvic floor relaxation due to estrogen depletion, Reduced renal blood flow -Pulmonary infections: Decreased cough reflex, Decreased elastic recoil of lungs, Decreased activity of cilia, Abnormal swallowing reflexes -Levels of stress, nutritional status, rest and sleep, medical therapy, preexisting disease process

Clostridium Difficile

-Spore -Symptoms: diarrhea -Infected should be kept separated so they dont infect a roommate (isolation) -Dont use tools that need to be taken out of room -All objects in room need to be wiped down with bleach to kill spores -Alcohol-based hand sanitizers dont work. Must use soap and water!!

Normal ranges for VS in adults and older adults

-Temperature: 98.6 F and 36-37.5 C Oral: 37 c Rectal: 37.5 Axillary: 36.5 C older, adult: 36 C BP: 120/80 Pulse 60-100 RR: 12-20

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply. The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room. The nurse is exiting a room after completed indwelling urinary catheter care. The nurse has assisted a client with changing and caring for a new colostomy.

-The nurse is going from one room to another to introduce themself at the start of the shift. -The nurse has entered the client's room to adjust settings on the intravenous pump. -The nurse has just completed documentation and is entering another client's room. -Explanation: Alcohol-based handrub is preferred in situations when hands are not visibly soiled; before and after touching a client; before handling an invasive device for client care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; and after removing sterile or nonsterile gloves. Use of an alcohol-based handrub does not replace the need for gloves or for handwashing, however. After performing catheter care and assisting with changing a colostomy, gloves are worn and handwashing should take place.

pouring a sterile solution

-The outer surfaces of the bottle and cap are considered unsterile, whereas the inside areas and the solution are considered sterile. -After a solution has been opened, the outer bottle should be labeled with date and time if it is to be reused. Most solutions are considered sterile for 24 hours after they are opened -When pouring from a bottle, grasp the bottle so that the label is in the palm of your hand. This action prevents any of the liquid from running over the label and making it illegible -Avoid splashing the liquid since this would contaminate the sterile field

Nursing interventions to promote medical asepsis

-To prevent susceptible hosts from infectious agent: Immunizations -To prevent infectious agent to reservoir: Hand hygiene, sterilization, antibiotics/microbials -To prevent reservoir from portal of exit from reservoir: Transmission based precautions, sterilication or use of disposable supplies .........................

contact precautions

-Use these for patients who are infected or colonized by a multidrug-resistant organism (MDRO). -Place the patient in a private room, if available. -Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. -Change gloves after having contact with infective material. -Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. -Limit movement of the patient out of the room.Avoid sharing patient-care equipment

axillary temperatures

-Used for all clients, preferred in newborns Non evasive -Less accurate (measures body surface temp -Must be left in place longer -Contraindicated in confused or combative clients

VRE (Vancomycin Resistant Enterococcus)

-Wear gown and gloves -Enterococcus found in GI tract -Need to be in isolation room -Contact isolation

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action?

Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider. -Explanation: If the pain is unexpected, notify the primary care provider because the client may be developing a deep vein thrombosis. Applying padding would be an insufficient response, and it would be dangerous to proceed with applying the stocking

lowest body temp time

4-6am is the lowest body temp (changes during day)

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?

40 mmHg -Explanation: The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. A newborn who has hypothermia A child who has pneumonia An older adult who is post MI (heart attack) A teenager who has leukemia A patient receiving erythropoietin to replace red blood cells An adult patient who is newly diagnosed with pancreatitis

A newborn who has hypothermia, An older adult who is post MI (heart attack)A teenager who has leukemia, A patient receiving erythropoietin to replace red blood cells -Explanation: The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken.** Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts.

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply Blood pressure decreases with age. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause. Blood pressure decreases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent in African Americans.

Blood pressure is usually lowest on arising in the morning, Women usually have lower blood pressure than men until menopause, Blood pressure tends to be lower in the prone or supine position, Increased blood pressure is more prevalent in African Americans. -Explanation: Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women.

The nurse is assessing a middle-aged adult age 48 years in the clinic. The nurse recalls the changes that occur in middle age as they complete the physical and cognitive examination. Changes that occur include what? Cardiac output decreases. Loss of fatty tissue Low-pitched sounds are more difficult. Visual acuity changes with myopia.

Cardiac output decreases -Explanation: Middle age changes include the following: redistribution of fatty tissue around the middle and abdomen; drier skin; wrinkles develop; hair grays and men may experience baldness; cardiac output decreases; near-vision diminishes; presbyopia; hearing diminishes, especially high-pitched sounds; hormone levels decrease; calcium loss from bone occurs; decrease in muscle strength.

The health care provider tells the nurse that the older adult client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking. -Explanation: Presbycusis is the loss of high frequency, sensorineural hearing. Background noise further aggravates hearing deficit, so limiting noise would help the client to hear better. Clearing pathways in the room would be used for a client with visual impairment. Clear communication regarding self-care activities would be used for a confused client. Routine oral hygiene is useful for clients with taste alterations

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply.

Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step? -Touch the tip of the bottle to the sterile container to start the flow of the solution and pour it into the container directly from the top of the container edge. -Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm). -"Lip" a new or old bottle of solution before pouring it and hold the solution with the label facing out from a height of 4 to 6 in (10 to 15 cm). -Hold the bottle inside the 1-inch edges of the sterile field with the label side facing the palm of the hand, then pour from a height of 2 to 4 in (5 to 10 cm).

Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm). -Explanation: Holding the bottle outside the edge of the sterile field with the label side facing the palm of the hand and preparing to pour from a height of 4 to 6 in (10 to 15 cm) is the correct step for adding a sterile solution. The tip of the solutions should never touch the container or dressing, and the label should face the palm when pouring the solution. Only a used bottle of solution needs to be lipped. The bottle should be held outside the edge of the sterile field

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. -Explanation: Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications

meds that increase respiratory rate and depth

ampthetamines and cocaine

A healthy 52-year-old client asks the nurse what she can do to maintain her health. Which of the following does the nurse recommend?

Perform self-examination of the skin every month -Explanation: Guidelines for health-related screenings, examinations and immunizations for the adult include self-examination of the skin every month; beginning at age 50, colonoscopy every 3-5 years; physical examination every year from age 40; the zoster vaccine is recommended for adults 60 years and older

An older adult client comes to the senior center for a check-up. During the visit, the client tells the nurse that he knows he should be more active than he is. The nurse reinforces the client's statement, explaining that physical activity helps to lower the risk of which condition? Select all that apply.

Physical activity is good for all people including the older adult. Being physically active (1) lowers the risk of heart disease, stroke, and diabetes, (2) reduces depression symptoms, and (3) improves thinking (Health People 2020). Staying active will increase or maintain strength and balance, allowing for continued independence and the prevention of injuries. Activity may be used to address symptoms of anxiety but it will not help lower the risk for anxiety. Arthritis can interfere with the older adult's ability to engage in physical activity.

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. The patient takes time to think about responses to questions. The patient is 86 years old.The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). The patient reports increased pain in right hip when repositioning in bed or chair.

Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

The nurse discovers during assessment that the client has an altered temperature.

Radiation: infrared heat waves Conduction: the air itself Evaporation: through sweating Convection: exposure to a fan by "goose bumps" or piloerection -Explanation: Radiation is heat that is lost to infrared heat waves. It can be accelerated by exposing the skin to the heat waves or prevented by covering the skin. Conduction describes heat that is lost by transfering from one object to the next. For example, heat is lost from the skin to the air or to water. Evaporation consists of heat loss that occurs as water is transformed into a gas, such as with sweating. Convection facilitates heat loss via passing air, such as with a breeze or a fan. Arterioveous shunts may remain open to facilitate the dissapation of heat from the body. A passing breeze facilitates heat loss via convection. In response to the body's temperature the sympathetic nervous system controls the opening and closing of arteriovenous shunts. Shivering is one mechanism for the body to retain heat. Heat can be lost through uncovered body surfaces by the physical process of radiation. Water in the form of a tepid bath or swimming is one way heat loss can occur through conduction. Insensible loss of body fluids is a form of evaporation that takes place on the skin. "Goose bumps" or piloerection is a natural response of the body to retain heat by reducting the surface area of the skin.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? -Clostridium difficile and diabetic ketoacidosis -Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) -Tuberculosis and pneumonia -Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) -Explanation: Reactive airway disease and exacerbation of COPD are both medical diagnoses and not communicable conditions. Clients with these conditions can room together. C. difficile requires contact isolation and is contagious. Diabetic ketoacidosis is considered a medical diagnosis and requires standard precautions. A surgical incision from an appendectomy is considered clean. A draining leg ulcer can transmit an infection to a client with a clean surgical incision. In both of these cases, rooming these clients together violates infection control standards. Tuberculosis requires airborne precautions and pneumonia requires standard precautions. Based on the mode of transmission of tuberculosis, these clients cannot room together

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?

Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. Common conditions that result from sensory deprivation include inaccurate perception of sights, sounds, tastes, and smells; inability to control the direction of thought; and difficulty with memory, problem solving, and performing tasks. Decreased coordination and equilibrium, lack of a caring attitude, and unstable moods are also common conditions associated with sensory deprivation

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up. -Explanation: A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard service with the palm upward. Using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg. -Explanation: The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique -Explanation: Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next? -Recheck BP level to ensure accuracy -Take pulse again to assess for tachycardia -Wait 20 minutes and recheck oral temperature. -Talk with client to allow them to relax before retaking vital signs.

Take pulse again to assess for tachycardia -Explanation: Normal ranges of vital signs for older adults are as follows: Pulse 60-100 Respiration 12-20 Temperature 96.4-99.5F (35.8-37.5C) Blood Pressure 90-120 /60-80. Reassessing pulse would be justified to determine if there is a tachycardia issue or if the client has situational anxiety, etc. that may affect the pulse rate. Talking with the client to help relax them is a common practice, but not warranted in this situation. The oral temperature is within normal limits so there is not need to retake it

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan?

The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. The client has reports of pain of 8 on a scale of 0 to 10 The client has a blood pressure of 122/70 mm Hg The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C) The client has been drinking water

The client has reports of pain of 8 on a scale of 0 to 10, The client just finished ambulating with physical therapy, The client has a temperature of 101.8°F (38.8°C) -Explanation: There are several factors that may cause an increase in heart rate due to an increase in metabolic rate. This can occur with pain, exercise, fever, medications, and strong emotions. A blood pressure of 120/70 mm Hg does not indicate an association with tachycardia or that a client has been drinking water. Caffeinated beverages may cause an increase in heart rate but water would not

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this? The thermometer is broken. The client is showing initial signs of infection. A rectal thermometer must be used. The client is covered with a couple of thick blankets.

The client is covered with a couple of thick blankets. -Explanation: Ordinarily, changes in environmental temperatures do not affect core body temperature, but core body temperature can be altered by exposure to hot or cold extremes such as blankets. The degree of change relates to the temperature, humidity, and length of exposure. The body's thermoregulatory mechanisms are also influential, especially in infants and older adults who have diminished control mechanisms. Using a rectal thermometer or assuming the thermometer is broken is not correct. The client is not exhibiting signs of infection as these may include an elevated temperature, an elevated white blood cell count, general malaise, and body aches

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs? The first audible sounds begin to decrease in intensity. The first audible sounds cease to be distinct. The initial Korotkoff sounds peak in intensity. The first faint, but clear, sound appears

The first faint, but clear, sound appears. -Explanation: The first faint, but clear, sound that appears and slowly increases in intensity constitutes the systolic pressure. Each of the other listed sounds would yield an inaccurate SBP reading

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended?

The nurse should use the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track, thus minimizing discomfort. The nurse should select a needle of the smallest gauge that is appropriate for the site and solution to be injected, and select the correct needle length. The nurse should also inject the medication into relaxed muscles since there is more pressure and discomfort if medication is injected into contracted muscles. The nurse should apply gentle pressure after injection, unless this technique is contraindicated.

For which client would the use of standard precautions alone be appropriate?

an incontinent client in a nursing home who has diarrhea -Explanation: Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat. Transmission-based precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as is the case in answers A, B, and D

A nurse working in a community clinic assists middle-age clients to follow guidelines for health-related screenings and immunizations. What preventive measures would the nurse recommend for this population? Select all that apply.

The nurse would recommend several different preventive measure that are listed. The nurse would recommend that the client have a physical exam every year from age 40 on; that the female client do a breast self-examination every month; a pelvic examination and Pap test at least every 3 years for women; a prostate-specific antigen (PSA) test every year for men; and a Zoster vaccine live vaccination for adults 50 years and older. The nurse would recommend a clinical skin examination every year.

Which client's blood pressure best describes the condition called hypotension?

The systolic reading is below 100 and diastolic reading is below 60. -Explanation: Hypotension is defined by a systolic pressure below 100 mm Hg and diastolic pressure less than 60 mm Hg. The top number refers to the amount of pressure in the arteries during the contraction of heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Ideal blood pressure is less than 140/90

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device. -Explanation: Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses

Droplet precautions

Use these for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Use a private room, if available. -Door may remain open. -Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. -Transport patient out of room only when necessary and place a surgical mask on the patient if possible-Keep visitors 3 ft from the infected person

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply.

When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

The nurse has applied personal protective equipment (PPE) before caring for an immunocompromised client. When removing PPE, what action should the nurse perform?

When removing gloves, the nurse should do so by pulling on the cuff with two fingers, being careful not to touch the outside of the contaminated glove. The nurse should not touch the outside of the contaminated gown.

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature? a 5 year-old with diarrhea a 2 month-old who has been crying for the past 2 hours a 65 year-old male who just finished drinking coffee a 26 year-old client with tetraplegia

a 65 year-old male who just finished drinking coffee -Explanation: Hot or cold drinks may cause variations in oral temperature readings; in this scenario a rectal temperature reading will be more accurate. The rectal site should not be used in newborns, children with diarrhea, and in clients who have undergone rectal surgery or have a disease of the rectum. Because the insertion of the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature for clients with heart disease or after cardiac surgery may not be allowed in some institutions. In addition, assessing a rectal temperature is contraindicated in clients who are neutropenic (have low white blood cell counts, such as in leukemia) and in clients who have certain neurologic disorders (e.g., spinal cord injuries)

The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?

assess temperature -Explanation: The client is showing signs of a fever, which can include pinkish, flushed skin that is warm to touch, restlessness or excessive sleepiness, irritability, poor appetite, glassy eyes and sensitivity to light, increased perspiration, headache, above normal pulse and respiratory rate, disorientation and confusion, convulsions in infants and children, and fever blisters. The nurse should first assess the temperature and then take further steps to care for the client, which will include notifying the health care provider. Letting the client continue to sleep after appropriate treatment will be beneficial to the client. It would also be appropriate to assess all the vital signs; however, the temperature would be the priority in this situation

contraindications for rectal temperatures

cardiac patients (**stimulation of sphincter can cause vagal stimulation which slows the heart rate and people can pass out**), -patients with diarrhea or rectal surgery, -neutropenic clients (cancer). -Low platelet counts (risk for bleeding), some agencies advise agaisnt use with neonates

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?

contact precautions -Explanation: VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin?

droplet

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?

performing careful hygiene

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

place a small pillow under each arm -Explanation: A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

place the specimens into plastic biohazard bags Explanation: Specimens should be placed in sealed plastic bags to prevent them from becoming contaminated or causing the transmission of infective microorganisms. Paper bags are not used for this purpose, and it is not customary to swab the outsides of specimen containers. Standard precautions should be implemented, but this does not necessitate the use of a gown in all cases

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi -Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

prone -Explanation: Placing the client in prone position allows for better arterial oxygenation, which may assist in healing of skin breakdown. The other positions place pressure on the areas of skin breakdown and are therefore incorrect

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

remove gloves, remove gown, wash hands -Explanation: The nurse will remove and dispose of the most contaminated items first, then dispose of other items, and then wash hands. Gloves should be first removed, then the gown. Then, hands are washed. The other answers are incorrect

hypothermia

small children, infants who cannot regulate temp, alcoholism, malnutriton, hypothyroidism, -Interventions: warm environment, dry clothing, supply warm IV fluids

The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention? blood pressure 116/80 mm Hg respirations 18 breaths/min pulse rate 70 beats/min temporal temperature 100.8º F (38.2º C)

temporal temperature 100.8º F (38.2º C) -Explanation: The nurse should intervene when the client's temperature is 100.5º F (38.2º C) or higher. If the adult's blood pressure is higher than 120/80 mm Hg or respirations more than 20 breaths/min or pulse rate greater than 100 beats/min, then these would also require the nurse to take appropriate action

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? the ability of the arteries to stretch the thickness of circulating blood the oxygen levels in the blood the volume of air entering the lungs

the ability of the arteries to stretch -Explanation: Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs