Nursing 246 Final

Barriers to effective nurse-client communication include:

•False reassurance •Interrupting •Changing the subject •Passing judgment •Cross-examination •Using technical terminology •Encountering sensitive issues

Venous edema vs Arterial edema

Venous: normal color, normal pulse, normal temperature Arterial: pale, cool, decreased pulse, minimal edema, thin, shiny skin, decreased hair

It is appropriate for a nurse to delegate obtaining vital signs for clients who are ______ and have a _________ condition

stable; chronic condition

Interview Techniques include:

•Observation •Open-ended questions •Leading questions •Back channeling •Direct closed-ended questions

Positive-pressure airflow is used for clients who

who have immune-system compromise

Serous drainage is

yellowish

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Select all that apply -Bathe a client who had an amputation 2 days ago -Assist a client to ambulate using a gait belt -Feed a client who had a stroke 3 months ago -Review a low-sodium diet for a client who has hypertension -Explain oral hygiene to a client receiving chemotherapy

-Bathe a client who had an amputation 2 days ago -Assist a client to ambulate using a gait belt -Feed a client who had a stroke 3 months ago

What does the RACE acronym stand for?

-Rescue The Patient -Activate Alarm -Confine -Extinguish

Which of the following are included in the assessment of a peripheral artery?

-Strength -The elasticity of the vessel wall -Bilateral equality -Pulse

Normal findings within the expected reference range for an abdominal assessment include:

-Symmetrical convex sphere shape -Concave umbilicus -Bilateral bowel sounds in lower quadrants

Documentation of pitting edema of less than 2mm is

1+

6 rights of medication administration

1. Patient 2. Drug 3.Dose 4. Route 5. Time 6. Documentation

Documentation of pitting edema of 2-4 mm is

2+

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? Select all that apply 1. Providing hygiene care to a client who is HIV-positive 2. Emptying a urinary drainage bag for a client who has pneumonia 3. Irrigating a client's abdominal wound 4. Transporting a cerebrospinal fluid specimen to the laboratory 5. Suctioning a client's new tracheostomy tube

3 & 5

Documentation of pitting edema of 5-7mm is

3+

Documentation of pitting edema of more than 7mm is

4+

Stridor

A continuous, shrill musical sound of constant pitch

Crackles

A series of short, interrupted, high-pitched sounds audible just before the end of the inspiration. The sound is similar to that of rolling hair between the fingers just behind the ear

Neuro assessments include

A&O x 4, pupils, hand grasps, feet pushes

Different means of good communication

Active listening, paraphrasing, clarifying, sharing empathy, validation, etc.,.

Purpose of PCA pump

Allows the patient to self-administer pain meds with minimal risk of overdose

This client presents with decreased or absent peripheral pulses; breath sounds are not affected by this

Arterial Thrombus

What might a patient need if their hemoglobin and hematocrit are low?

Blood transfusion

Where can you put a nitroglycerin patch on patients

Chest, back, flank, upper arm. No elbows or below knees. Intact, non-irritated skin.

Nonantimicrobial soap is used when in contact with spore-forming organisms such as

Clostridium difficile or Bacillus anthracis

What do you assess for when a patient urinates?

Color, clarity, and odor of urine

What are the three different types of isolation? What PPE is required for each? What type of patient would require each?

Contact: Gastrointestinal illness (diarrhea) Droplet: Influenza, and other respiratory illnesses such as corona virus Airborne: TB, measles, chickenpox

Rhonchi

Continuous rumbling, snoring, or rattling sounds resulting from fluid or mucous

Wheezing

Continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope

What are thesigns a patient might need their trach suctioned?

Crackles, cough, drooling, restlessness, decreased 02 sat, increased HR, increased RR

What to check for an IV site

Edema, pain, redness, warmth, coolness

A client is on strict bed rest following a total hip replacement. The nurse suspects the client has developed a Deep Vein Thrombosis when she asses which of the following in the right lower extremity? Select all that apply

Edema, pain, redness, warmth, decreased pulses

Routes for enteral vs parenteral feedings

Enteral: to the stomach Parenteral: Through a vein

Which type of catheter requires inflation?

Indwelling catheters

Signs of bowel obstruction

Nausea and vomiting; pain; no bowel movements; no bowel sounds; distention

Sensory overload vs Sensory deprivation

Overload: Occurs when a person receives multiple sensory stimuli and cannot disregard or ignore some of the stimuli Deprivation: Reduced sensory input, elimination of patterns or meaning from input, or restrictive environments

What to do for patients who are experiencing a seizure

Padded bed rails, oxygen and suction at bedside, nothing in mouth, record time, turn patient to side etc.,.

Peripheral vs Central IV

Peripheral: Inserted into a peripheral vein; temporary access Central: Terminates near the right atrium; more stable, strong meds, multiple meds, frequent blood draws

A client presents with crackles in the lungs due to increased secretions; the breath sounds are not absent

Pneumonia

What does PASS stand for?

Pull, Aim, Squeeze, Sweep

This client presents with sudden chest pain, shortness of breath, and a decreased blood pressure

Pulmonary embolism

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Reach around the pack and open the top flap away from the body; The nurse should pull the uppermost flap away from her body, grasping it from the side to avoid reaching over the sterile field and contaminating it.

Nonverbal indications for a patient who has pain may include:

Restlessness, grimacing, clenching

Methods of DVT prevention

SCD's, IS, turn frequently, lovenox (anticoagulant), Ted HOSE, special mattress, ROM, high calorie/high protein diet, adequate fluid intake and outtake, etc.,.

Name 4 out of 6 factors that are assessed using the Braden scale

Sensory perception, moisture, activity, mobility, nutrition, friction and shear

A patient was admitted following a motor-vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of a pneumothorax. Which are the most common assessment findings associated with a pneumothorax?

Sharp pleuritic pain that worsens on inspiration, worsening dyspnea, absent or diminished lung sound on the affected side

Stress incontinence vs Urge incontinence

Stress: weakness or injury to the urinary sphincter; happens after birthing; can occur with sneezing or coughing Urge: involuntary passage of urine associated with strong sense of urgency; involuntary contractions of the bladder, or overactive bladder Signs and symptoms- urgency. frequency, nocturia, leakage

A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac - rather than respiratory or gastrointestinal when it:

When it does not change with respiratory variations

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? a. 25 mg/dL b. 13 mg/dL c. 10 mg/dL d. 18 mg/dL

a. 25mg/dL; the expected reference range for BUN values is 10-20 mg/dL. If the BUN is above this range, the kidneys might be having difficulty excreting urea and nitrogen. Elevation can be seen in dehydration and might require the use of intravenous fluids.

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? a. Atelectasis b. Pneumonia c. Pulmonary embolism d. Arterial thrombus

a. Atelectasis; an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? a. Attach a humidifier bottle to the base of the flow meter b. Remove the nasal cannula while the client eats c. Secure the oxygen to the bed sheet near the client's head d. Apply petroleum jelly to the nares as needed to soothe the mucous membranes

a. Attach a humidifier bottle to the base of the flow meter; oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4L/min via nasal cannula

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? a. When the client has the urge to defecate b. Every 2 hours while client is awake c. Immediately before the client has a meal d. After the client feel abdominal cramping

a. When client has the urge to defecate

A nurse is assessing a client's radial pulse and determines that the pulse is irregular, which of the following actions should the nurse take? a. assess the apical pulse for a full minute b. assess the apical pulse with a doppler device c. assess the pedal pulses for a full minute d. assess the pedal pulses with a doppler device

a. assess the apical pulse for a full minute

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? a. explain to the client what is about to happen b. make sure the room temp is cool c. provide music as an environmental distraction d. inform the client that the provider will examine sensitive areas first

a. explain to the client what is about to happen

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? a. the left second intercostal space b. the right second intercostal space c. the left intercostal space d. the left fifth intercostal space at the midclavicular line

a. the left second intercostal space

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? a. place her hands on the sides of her rib cage b. inhale slowly and evenly through her nose c. hold her breath for at least 10 seconds d. exhale forcefully through the nose

b inhale slowly and evenlythrough her nose

A nurse is planning care for a group of clients. The nurse should delegate obtaining vital signs to an AP for which of the following clients? (Select all that apply) a. A middle adult client who has status asthmaticus b. An older adult client who has a history of heart failure and is ready for discharge c. A young adult client who is 24 hr postoperative following an appendectomy d. An older adult client who is 36 hr postoperative from a traditional cholecystectomy e. A young adult client receiving a continuous IV infusion of regular insulin diabetic ketoacidosis

b, c, d

A nurse is assessing a client for pitting edema and notes an indentation of 6mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema a. 4+ b. 3+ c. 2+ d. 1+

b. 3+; nurse should document the pitting edema of 5-7 mm as 3+

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following? a. Steatorrhea b. Blood c. Bacteria d. Parasites

b. Blood; the guaiac test detects the presence of occult of hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take first? a. Keep the container of solution at a level to maintain client comfort b. Hold the container of solution 30 cm (12in) above the anus c. Hold the container of solution level with the client's upper hip d. Hold the container of solution 15cm (6in) above the anus, then lower it to 15cm below the anus

b. Hold the container of solution 30cm (12in) above the anus; allows for continuous, slow instillation of solution to promote evacuation of feces in the bowel.

A nurse is caring for a client who experienced an infection at the insertion site of her IV catheter. Which of the following findings should the nurse expect? a. The client reports numbness at the site b. Purulent drainage is noted from the site c. The vein appears cordlike d. Skin over the site sloughing

b. Purulent drainage is noted from the site; signs of infection include warmth, redness, swelling, and possible purulent drainage

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the edema and allow him to go to the bathroom. Which of the following actions should the nurse take? a. Discontinue the enema b. Slow flow of enema solution briefly c. Continue the enema and reassure the client d. Pause the enema and administer oral pain medication

b. Slow the flow of enema solution briefly; slowing the enema solutions flow temporarily prevents cramping.

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client? a. Transdermal patch b. Sublingual c. Suspended-release d. Topical ointment

b. Sublingual

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE) Which of the following types of precautions should the nurse plan to initiate? a. droplet b. contact c. airborne d. protective

b. contact; contact precautions are a type of transmission-based precaution for clients who have an infection, such as VRE, which spreads either by direct or indirect contact

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of PPE should the nurse remove first? a. mask b. gloves c. gown d. goggles

b. gloves; the nurse should remove the gloves first, as they are the most contaminated

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention a. providing a community program on stress reduction b. performing monthly breast self-examinations c. teaching foot care to a client who has diabetes d. referring a client who has had a mastectomy to a support group

b. performing monthly breast self-examinations; secondary preventative care focuses on early detection.

A nurse is performing a cardiac assessment and auscultates an3s sound. The nurse should recognize that this sound represents which of the following heart conditions? a. atrial gallop b. ventricular gallop c. closure of the mitral valve d. closure of the pulmonic valve

b. ventricular gallop; can be a finding of heart failure and hypertension

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? a. place client in a room with negative airflow b. wear a mask when providing care to client c. ensure the client's room as HEPA filtration (airborne) d. wear a gown when providing care fore client

b. wear a mask when providing care for client; should be worn when within 3 feet of client who requires droplet precautions

Sanguineous drainage is

bloody

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? a. Inspecting the site for reduced swelling b. Monitoring the client's pulse rate c. Asking the client to rate the pain d. Having the client perform a range-of-motion of the affected arm

c .Asking the client to rate the pain

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention? a. A client who has an elevated BUN b. A client who reports painful urination c. A client who reports urinary frequency d. A client who has glucose in his urine

c. A client who reports urinary frequency; voiding small amounts of urine (less than 100mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? a. Pinnae of the ears b. Dorsal surface of the hand c. Conjunctivae d. Dorsal surface of the foot

c. Conjunctivae

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote THINNING of respiratory secretions? a. encourage the client to ambulate frequently b. Encourage coughing and deep breathing c. Encourage the client to increase fluid intake d. Encourage regular use of the incentive spirometer

c. Encourage the client to increase fluid intake; increasing fluid intake to 1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the clients ability to cough and remove the secretions

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? a. Blood Pressure b. Cyanosis c. Nausea d. Petechiae

c. Nausea; Subjective data include information that only the client can perceive and report; the nurse cannot determine that the client feels nauseated

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? a. Stress incontinence b. Urge incontinence c. Overflow incontinence d. Reflex incontinence

c. Overflow incontinence

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? a. Ask the provider about advancing a client's diet b. Reinsert an IV catheter that was removed due to infiltration c. Suction the tracheostomy of a client who has copious amounts of secretions d. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift

c. Suction the tracheostomy of a client who has copious amounts of secretions

A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. reposition the client every 3 hr b. massage bony prominences to promote circulation c. provide the client with a diet high in protein d. apply cornstarch to keep skin dry

c. provide client with a diet high in protein; inadequate intake of protein, iron, vitamins, and calories increase risk for skin breakdown

You are reviewing the chart of your patient and notice he has left-sided heart failure as a result of a myocardial infarction. Which assessment finding is consistent with this diagnosis? a. abdominal tenderness due to hepatomegaly b. peripheral edema to related to venous congestion c. shortness of breath from pulmonary edema d. vocal stridor from jugular distention

c. shortness of breath from pulmonary edema

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? a. use a stiff toothbrush to clean the client's teeth b. Use the thumb and index finger to keep the client's mouth open c. turn the client on his side before starting oral care d. apply petroleum jelly to the client's lips after oral care

c. turn the client on his side before starting oral care; placing the patient on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? a. hold gauze packages 7.6cm (3in) above sterile field b. place sterile supplies within 2.54 (1 in) border of sterile field c. use sterile forceps to move sterile items on the sterile field d. position the wrapped package on the bedside table so the outer flap opens towards her.

c. use sterile forceps to move the sterile items on the sterile field

A clinical nurse educator is preparing an educational program about transmission of MRSA (methicillin-resistant staphylococcus aureus) in hospitalized clients. Which of the following information should the nurse include in the program? a. Place clients who have MRSA on airborne precautions b. MRSA can be effectively treated with an antiviral medication c. MRSA can live on the hands for 1 hr d. Bathe the clients with water and chlorohexidine gluconate

d. Bathe the clients with water and chlorohexidine gluconate; bathing hospitalized patients with premoistened cloths or warm water that is mixed with chlorohexidine gluconate significantly decreases the infection with MRSA

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result the long-term inadequate oxygenation? a. Restlessness b. Retractions c. Dependent enema d. Clubbing of the fingers

d. Clubbing of the fingers

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? a. clamps the BG tube during auscultation b. Performs auscultation between meals c. Auscultates bowel sounds for 3-5 minutes d. Palpates the abdomen prior to auscultation

d. Palpates the abdomen prior to auscultation; palpation should come after auscultation

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? a. Serous b. Purulent c. Sanguineous d. Serosanguineous

d. Serosanguineous; watery red

The nurse is caring for a patient with a chest tube system. The nurse assess the closed system and notes the following: The tube is secured to the chest wall, there are no kinks in the tubing and the drainage system is below the patient's chest. The nurse also notes constant bubbling in the water-seal chamber. The nurse recognizes: a. an immediate need to clamp the chest tube b. she should document the findings as a normal assessment c. she should raise the chest tube above the level of the patients chest d. she has found an indication that there is a leak in the drainage system and she should notify the provider immediately.

d. She has found an indication that there is a leak in the drainage system and she should notify the provider immediately.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? a. Bradypnea b. Somnolence c. Pallor d. Tachycardia

d. Tachycardia

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the should should measure the gastric residual for which of the following purposes? a. To confirm placement of the NG tube b. To remove gastric acid that might cause dyspepsia c. To determine the client's electrolyte balance d. To identify delayed gastric emptying

d. To identify delayed gastric emptying; the nurse should measure the amount of unabsorbed formula from the previous enteral feeding to identify for delayed gastric emptying. If it is delayed, the should avoid overfeeding the client and causing gastric distention

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? a. BUN b. Potassium c. RBC count d. WBC count

d. WBC count; an elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection

A patient with a history of CHF is experiencing acute onset of shortness of breath and is speaking 1-2 word sentences. What is the appropriate supplemental oxygen for this patient? a. nasal cannula at b lpm b. nonrebreather at 2-6 lpm c. endotracheal intubation d. nonrebreather at 10-15 lpm

d. nonrebreather at 10-15 lpm

The nurse is assessing a client who just had a nasogastric tube placed. What is the priority action for the nurse to take? a. irrigate the tube with normal saline b. check the PH of the gastric content c. connect the tube to intermittent suction d. obtain an x-ray to verify tube placement

d. obtain an x-ray to verify tube placement

When performing an assessment, you observe 3+ pitting edema in the client's lower extremities. The client indicates that the swelling can get severe at times. They can't put on their shoes and reports the swelling goes down when they elevate their feet. Which condition will you MOST likely observe written in the patient's medical record? a. atrial fibrillation b. left-sided heart failure c. myocardial infarction d. right-sided heart failure

d. right-sided heart failure

A client who has a urinary tract infection has urine that appears:

dark amber, cloudy, and concentrated because of the presence of WBCs, RBC's, and bacteria, has an unpleasant odor,

The ____ is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation

earlobe

High, low, and normal blood glucose levels

normal range: 70-110 High: Diabetes, stress, steroids Low: Newborns, insulin shock, adrenal insufficiency

A systolic murmur can be heard when the nurse hears turbulence between the ___ and ____ heart sounds

s1 & s2

Purulent drainage is

thick and odorous