Test 3 NUR 151 (Other stuff)

The client asks the nurse how to administer medication purchased over the counter for relief of arthritis pain. The nurse reviews the medication and determines that it is to be applied topically. Which instructions should the nurse provide?

*Apply the medication to clean, dry skin of the affected area using gloves.

You are to administer a medication to Mr. Brown. In addition to checking his identification bracelet, you can correctly verify his identity by doing which of the following?

*Asking the patient his name

A nurse has made a medication error. Which of the following should be the first response?

*Assess patient's condition for any possible effect of the error.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

*Assess the client's wound and vital signs. -First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain.

A nurse is planning to administer medication to a client. Which of the following should be the last check the nurse completes when reviewing the medication against the medication administration record (MAR)?

*Before administering the medication to the client

A physician has ordered subcutaneous injections of morphine every 4 hours as needed for pain for a motor vehicle accident victim. Morphine has a high abuse potential and is categorized in which class of drugs?

*C-II Narcotics such as morphine are considered C-II drugs because of the high abuse potential with severe dependence liability.

What are C-III drugs?

*C-III drugs have a lesser abuse potential than C-II drugs and an accepted medical use.

What are C-IV Drugs?

*C-IV drugs have a low abuse potential and limited dependence liability.

Category X drugs-

*Category X drugs carry the risk of fetal abnormalities. The risk of use in pregnant women clearly outweighs any possible benefit.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

*Client-centered care *Teamwork and collaboration *Quality improvement (QI)

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

*Conceal IV tubing with gauze wrap.

Which is not considered a skin appendage?

*Connective tissue- The dermis is composed of connective tissue.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

*Discontinue the therapy and assess the client.

What is Distribution?

*Distribution involves the transport of drug molecules within the body.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

*Document the findings. -The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse.

A nurse is responsible for maintaining an accurate count and record of the controlled substances on the nursing division. This nursing action is regulated by which law or agency?

*Drug Enforcement Administration

Phase III Drug Trial-

*During phase III, it is determined if the drug's benefits outweigh the adverse effects.

Phase IV Drug Trial-

*During phase IV of a drug trial, it is the manufacturer's responsibility to continue to monitor the drug's effects while the drug has been placed in general use.

The nurse is assessing a client with diabetes who has poor vision. Which feature of the insulin pen makes it beneficial for this client?

*Each unit of insulin is accompanied by a clicking sound in the pen.

What is Enteral Tube Feeding?

*Enteral feeding refers to intake of food via the gastrointestinal (GI) tract. The GI tract is composed of the mouth, esophagus, stomach, and intestines.

What is First Pass Effect?

*First-pass effect is a phenomenon in which drugs given orally are carried directly to the liver after absorption, where they may be largely inactivated by liver enzymes before they can enter the general circulation.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

*Fish- To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

*Flush the eyes with water for 10 minutes. -If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.

What is Foot Drop?

*Foot drop is a contracture in which the foot is fixed in plantar flexion. A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility.

What is a Hemovac & JP drain used for?

*Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage.

What are Hydrocolloid Dressings?

*Hydrocolloids- are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing.

What are Hydrogel Dressings?

*Hydrogels- maintain a moist wound environment and are best for partial or full-thickness wounds.

The nurse knows that a client is at high risk for developing drug tolerance because the client will be taking which drug for a long period of time?

*Hydromorphone (Dilaudid) for pain

A nurse is caring for a client who refuses to take the prescribed medication, stating that she is allergic to it. What should the nurse do when the client refuses to take the medication? Select all that apply.

*Identify the reason for not administering. *Circle the scheduled time on the MAR. *Report the situation to the prescriber.

Phase II of clinical testing

*In phase II of clinical testing, the drug is given to clients with the disease for which the drug is manufactured.

How often should infected wound dressings be changed?

*Infected wounds may require dressing changes every 12 to 24 hours.

The nurse is preparing to administer an allergy test via an intradermal injection. Which injection site would be most appropriate in this situation?

*Inner surface of the forearm. -Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula.

What is the Intramuscular route?

*Intramuscular (IM) route- is reserved for drugs to be injected in the muscle. *90-degree angle -The deltoid muscle of the shoulder are common injection sites.

What is Maceration?

*Maceration- is localized wound overhydration or excessive moisture.

Maturation phase of Wound Healing-

*Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

What is Metabolism?

*Metabolism is the method by which drugs are inactivated or biotransformed by the body.

What is Necrosis?

*Necrosis- is death of tissue in the wound.

If the dosage is inappropriate for a client, who is responsible?

*Nurse

Over the Counter Drugs (OTC):

*Over-the-counter (OTC) drugs are available without a prescription for self-treatment of various ailments.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

*Peer pressure causes children of this age to take risks.

What is pharmacology?

*Pharmacology is the all-encompassing term for the study of the biological effects of chemicals.

What is Pharmacotherapeutics?

*Pharmacotherapeutics is a branch of pharmacology specifically focused on the use of drugs as therapy, to treat, prevent, and diagnose disease.

Phase I of Clinical Testing

*Phase I of clinical testing involves 20 to 100 healthy volunteers.

School-aged children are vulnerable to injuries related to?

*Play-related injuries are commonly seen in school-age children

What type of PPE should be worn w/ a PT who has Pneumonia?

*Pneumonia requires DROPLET precautions, including a gown, mask, and gloves.

Stage I

*Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

*The alternative measures attempted before applying the restraints.

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply.

*The care team meets with the client and family promptly to identify their preferences for treatment. *The care team balances the best available evidence about glioblastoma treatment with the client's preferences. *Nurses proactively identify threats to the client's safety that may occur as treatment is provided. *Each member of the care team uses the best available technology to organize and provide

Dermis-

*The dermis contains the nerves, hair follicles, blood vessels, and glands.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

*The hospital must bear any costs incurred for treating the client's injury. -If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital.

Third degree burns:

*Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

*To splint the area when engaging in activity. -To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating.

What are Trochanter Rolls?

*Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward.

A medication order reads: "K-Dur, 20 mEq, PO b.i.d." When does the nurse correctly give this drug?

*Twice a day by the oral route

What is healing by Secondary Intention?

*Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention.

A nurse is reviewing the medication administration record of a client who has difficulty swallowing. Which of the following medications should the nurse identify as safe to crush before administering to client?

*acetaminophen caplet

What are Category D Drugs?

*category D drugs, there is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite these potential risks.

When educating families on fire safety, it is important to:

*have a meeting place outside the home.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

*transparent- Transparent dressings are used to protect intravenous insertion sites.

noncommunicable disease

-A noncommunicable disease is caused by food or environmental toxin.

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.

-Incubation period -Prodromal stage -Full stage of illness -Convalescent period

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus?

"I probably got the virus when I sat on the toilet seat in a dirty bathroom." -The virus cannot be contracted or spread through a toilet seat.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?

"I will obtain a mask from the staff and wash my hands before touching my family member."

The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask?

*"Do you get all of your medications filled at the same pharmacy?"

A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

*0.5.

The nurse provides health education for a diverse group of clients. For which client should the nurse emphasize the risk of teratogenic drug effects?

*20-year-old female client who has been diagnosed with a chlamydial infection -The risk of teratogenicity is a priority consideration for female clients of child-bearing age

The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client?

*90 degrees- Insulin injections are given subcutaneously to clients with obesity at a 90-degree angle.

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.

*Administer analgesia before changing the dressing around the drain, if needed. *Use a gauze pad to clean the drain outlet after emptying it. *Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

What are the 11 Patient RIGHTS of Medication admin?

1. Patient 2. Medication 3. Dose 4. Route 5. Time 6. Reason 7. Assessment 8. Documentation 9. Education 10. Response 11. Refusal

Admin of Parenteral Medications

1. Subcutaneous injection- subcutaneous tissue 2. Intramuscular Injection- Muscle tissue 3. Intradermal Injection- Corium (under epidermis) 4. Intravenous Injection- Vein 5. Intraarterial Injection- Artery 6. Intracardial Injection- Heart Tissue 7. Intraperitoneal Injection- Peritoneal Cavity 8. Intraspinal Injection- Spinal canal 9- Intraosseous Injection- Bone

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

Apply a nonparticulate (N-95) respirator when entering the room.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?

Avoid touching the outer surfaces of the gown.

The nurse is preparing to don (to put on) a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering the client's room.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?

Discard the bottle and get a new one because the saline has expired.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

Pre-FDA phase

In vitro testing of the drug on human or animal cells is done in the pre-FDA phase.

What is Mass Trauma Terrorism?

Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

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

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Pour the liquid into a sterile container within the sterile field.

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

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

Surgical asepsis technique

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

The client's immune system became further weakened

What is the Covalescent Period?

The convalescent period- is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the client's general condition. The signs and symptoms disappear, and the person returns to a healthy state.

Surgical asepsis is defined as:

absence of all microorganisms.

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?

contact

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

remind the student that a fitted N95 respirator is required

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

staff education on utilizing hand hygiene

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

Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes.

true

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

"Help me understand your thoughts about vaccinations."

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

*"Always provide close supervision for young children when they are in or around pools and bathtubs."

The nurse is teaching a nursing student regarding safety of chemotherapeutic medication. Which statement by the nurse is correct?

*"Antineoplastic drugs can be absorbed through the skin."

The charge nurse has just completed an inservice with a group of nursing students. One nurse student asks, "Why do I have to know how to give medications in different ways. I thought the unlicensed assistive personnel (UAP) performs those skills?" What is best response by the charge nurse?

*"Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes."

A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting?

*"I hold the boxes away from my body so I don't drop them on my feet."

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

*"I've set up this sterile field for your procedure, so please do not touch anything around the tray."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

*"Is your child breathing at this time?" -Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status.

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?

*"Medication stays in the chamber so you can continue to inhale it."

The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?

*"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

*"Reinforced adhesive skin closures will hold my wound together until it heals." -After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples.

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

*"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

*"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

*"Very little scar tissue will form."

How many PT identifiers should you use?

*2 1. asking patient name and DOB 2. comparing to id bracelet

The health care provider prescribes ciprofloxacin 500 mg PO q12h for a pediatric client with bronchial pneumonia. The nurse has liquid ciprofloxacin 250 mg/10 mL on hand. How many mL would the nurse dispense? Fill in the blank. Record your answer using a whole number.

*20 Order/ Available 500/250= 2 (10)= 20

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

*A hair dryer is placed next to the sink.

What is a Meter-Dose Inhaler?

*A meter-dose inhaler has a canister that contains medication under pressure.

What does teratogenic mean?

*A teratogen is an agent that can disturb the development of the embryo or fetus. (Birth defects).

*What is a ventriculoperitoneal shunt?

*A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

A medication order has ac written after the medication dosage. What does ac stand for?

*AC= Before meals.

What is the common maximum Volume of Intramuscular Injection?

*An intramuscular injection is the administration of up to 3 mL of medication into one muscle or muscle group.

What does "DAW" stand for?

*DAW= Dispense as Written.

A nurse is aware that older adults tend to have a significantly decreased rate of hepatic blood flow compared with younger adults. What effect is this likely to have on pharmacokinetics and pharmacodynamics in an older adult?

*Drug clearance is likely to be slower. -An age-related decline in hepatic blood flow that begins around the age of 40 years can affect serum concentration and volume of distribution of substances that are metabolized more extensively by the liver, even in healthy older adults.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

*Every 48 to 72 hours. -In a non-infected wound, the negative pressure dressing should be changed every 48 to 72 hours.

What does Exudate mean?

*Exudate- a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation.

Which piece of personal protective equipment (PPE) should be removed first?

*Gloves -The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

What is an Intradermal Route?

*Intradermal Route (IR)- is injecting the drug between the layers of the skin.

What is the Volume for Intradermal Injections?

*Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL.

Transdermal medication:

*Is A medication that is designed to produce systemic effects (occuring in the tissue distant from the site) and is absorbed through the skin.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

*It is a canister that contains pressurized medication. -A meter-dose inhaler has a canister that contains medication under pressure.

Maturation Healing-

*Maturation is the final stage of full-thickness wound healing.

What is Oxymetazoline?

*Oxymetazoline- is a nasal decongestant used to alleviate congestion.

What does the acronym RACE stand for?

*RACE stands for Rescue - Alarm - Contain - Extinguish.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

*Sims' -Sims' position, a semiprone position, can be used for certain examinations of the rectum and vagina.

Stage II

*Stage II involves blistering or a skin tear.

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 *Move client to a private room for safety precautions *Transmission-based precautions including proper disinfecting of equipment

Where are SUBLINGUAL Meds placed?

*Sublingual medications are placed under the tongue.

Tertiary Intention-

*Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

2nd phase of Wound Healing-

*The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound.

1st phase of Wound Healing-

*Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis.

Which client would most likely require placement of an implantable port?

*a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy

The nurse is educating a client on over-the-counter (OTC) medications. What information is required to be placed on the label of the medication? (Select all that apply.)

*adverse reactions *dosage of the medication *contraindications to the medication

What are Category A drugs?

*category A drugs, adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy, and there is no evidence of risk in later trimesters.

What are Category B Drugs?

*category B drugs, animal studies have not demonstrated a risk to the fetus, but there are no adequate studies in pregnant women.

What drug category indicates fetal risk where the risk outweighs any potential benefit?

*category X- Category X drugs carry the risk of fetal abnormalities. The risk of use in pregnant women clearly outweighs any possible benefit.

What are Antineoplastic Drugs?

*chemotherapy drugs- Antineoplastic drugs are absorbed through the skin and should always be handled with caution.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

*keeping sterile field above waist level.

Which level of health care provider may make the decision to apply physical restraints to a client?

*nurse practitioner

The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep?

*supine

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

*transparent -The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing.

What does Convalescent mean?

-A person who is recovering from an illness or operation.

Which microorganism causes ringworm in a client?

-Fungi- Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

-Fungi. *Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails.

What is Albumin?

-a protein made by the liver. Albumin helps keep fluid in your bloodstream.

Which practice is a correct application of infection control practices?

A nurse performs hand washing each time the nurse removes a pair of gloves.

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources

In which situation is an alcohol-based rub an inappropriate option for hand hygiene?

When the nurse's hands are visibly soiled

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

an incontinent client in a nursing home who has diarrhea

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

What is Pallor?

unhealthy pale appearance

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

urinary catheter

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift.

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

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all client care and interaction

What is a Penrose Drain used for?

*A Penrose drain provides a sinus tract for drainage.

Schedule V Drugs-

*Schedule V drugs have limited abuse potential.

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely?

*second degree or partial thickness.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

-surgical asepsis *Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

What is Medical asepsis?

Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

*15-degree angle- A 15-degree angle is correct, as this allows the drug to be injected between the layers of the skin.

which medication will delay the healing of the operative wound?

corticosteroids- corticosteroids decrease the inflammatory process, which may delay healing.

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

"All visitors who enter the room must wear special masks."

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?

"Help me understand your perspective about vaccinating."

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?

"The way you are doing it helps to minimize contamination of the non-waterproof side." -The sterile drape is to be positioned with the drape on work surface with the moisture-proof side down.

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known." *Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness.

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:

"You may have infection in your birth canal that you are unaware of." *Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

During a teaching session on self-administration of insulin, the client asks the nurse why it is necessary to bunch the skin before inserting the needle. What is the nurse's best response?

*"Bunching your skin facilitates the placement of the needle in the subcutaneous tissue."

The nurse is assessing a community-dwelling client with a history of rheumatoid arthritis. During the interview, the client states, "The last few months, I have this ringing in my ears that I just cannot seem to get away from." What assessment question should the nurse ask?

*"Have you been taking aspirin on a regular basis?" -Aspirin is a relatively common cause of tinnitus and auditory nerve damage.

The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern?

*"I feel like my back and arms are itching." -IV infusions have an immediate effect. The nurse should instruct the client to report any difficulty in breathing or signs of reaction such as itching.

A gerontological nurse is conducting a medication assessment of a new client on a subacute medicine unit. Which of the client's statements should signal to the nurse a need for education?

*"I use a lot of herbs and supplements, but I'm careful to make sure that they're all natural."

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

*"I will put a layer of cloth between my skin and the ice pack."

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

*"I will squeeze the chamber and apply the cap to maintain negative pressure." -The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours.

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

*"It provides a way to remove drainage and blood from the surgical wound."

A client diagnosed with diabetes mellitus has been started on insulin therapy to control glucose levels. The client does not want to take any medications that come from an animal source. What is the best response by the nurse?

*"Many forms of insulin, such as genetically engineered, do not use animal products."

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

*"Necrotic tissue is devitalized tissue that must be removed to promote healing." -The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic.

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

*"Put your arm in this sleeve." -When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed.

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

*"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

A client is taking numerous eye drops to prepare for cataract surgery. Which teaching about ophthalmic application will the nurse provide?

*"Wait 5 minutes between instillation of different types of eye drops." -The nurse will teach the patient to wait 5 minutes between instillation of different types of eye drops to facilitate best absorption.

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

*"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

*"Your wound will heal slowly as granulation tissue forms and fills the wound."

The nurse is working the night shift in the ER when an ambulance arrives carrying a man s/p motor vehicle accident (MVA). His initial BP is 100/56 and the nurse notes that he is bleeding heavily from a laceration on the forehead. Fifteen minutes later, the nurse reassesses the client and finds that his BP is 95/58. What IV fluid would the nurse expect to be ordered?

*0.9% NS- Isotonic fluids are used to increase blood pressure secondary to hypovolemia.

The nurse is preparing supplies for a tuberculosis screening. The nurse should choose which syringes and needles?

*1 mL syringe; ½-inch (1.25-cm), 26-gauge needle. -For a tuberculosis screening, the nurse should choose a 1 mL syringe with a ½-inch (1.25-cm), 26-gauge needle.

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

*1 mL- The volume of a subcutaneous injection is usually up to 1 mL.

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

*10 to 15 degrees- Intradermal injections are given at a 10- to 15-degree angle.

How many times should you check a medication?

*3 times. 1.When you pull the medication 2. Hold above MAR & check Med against MAR. 3. Comparing MED w/ MAR at patients bedside.

Factors Affecting absorption?

*6 1-Route of admin 2-lipid solubility 3-pH 4-blood flow 5-local conditions at site of admin 6-drug dosage

How many factors affect drug action?

*8 1- Developmental factors 2-WT 3-Gender 4-Culture 5-Genetic Factors 6-Pychological Factors 7-Pathology 8-Environment P.827

The nurse is preparing to insert an intravenous needle in a 1-year-old child for a one-time administration of fluids due to dehydration. Which needle would the nurse likely select?

*A 23-gauge winged infusion set. -Winged infusion or small vein needles may be used for short-term or one-time infusion therapies or may be used with infants and small children. These are short, beveled needles with plastic flaps or wings.

What is a Penrose Drain?

*A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

*A Penrose drain promotes passive drainage into a dressing. -A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing.

Which statement best defines how a chemical becomes termed a drug?

*A chemical must have a proven therapeutic value or efficacy without severe toxicity or damaging properties to become a drug. -Even though all the responses are correct, a chemical must undergo a series of tests to determine its therapeutic value and efficacy without severe toxicity or damaging properties before it is termed a drug. Test results are reported to the FDA, which may or may not give approval.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

*A client who has leg strength and can cooperate with the movement -The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance.

The nurse is preparing to administer a medication that he is unfamiliar with to a client. Which of the following resources should the nurse use to identify therapeutic use of the medication? Select all that apply.

*A drug application *A drug book -A drug book or application contains information about specific medications such as indications, actions, dosages, routes, adverse effects and client teaching. the nurse should consult a medication reference book or pharmacist when he is unfamiliar with prescribed medication.

What is a normal WBC count?

*A normal white blood cell count is 5,000 to 10,000 cells/mm3.

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply.

*A person with a history of falls is likely to fall again. *Some people are more at risk for accidents than others. *A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

Stage I Pressure Ulcer-

*A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

Stage II Pressure Ulcer-

*A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater.

Stage III Pressure Ulcer-

*A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. -Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling.

What is Absorption?

*Absorption is the process that occurs from the time the drug enters the body to the time it enters the bloodstream to be circulated.

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

*Adduction- Adduction is a lateral movement of a body part toward the midline of the body.

The nurse working on the medical-surgical unit is caring for four clients with varying needs. In which situation(s) would it be acceptable to use alcohol-based handrub? Select all that apply.

*After removing gloves following a dressing change *Before assessing a client's vital signs and performing edema measurement *Before handling an invasive device for client care

What are Alginates?

*Alginates- absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation).

When the client demonstrates a rash 30 minutes after taking a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?

*Allergy- Allergic reactions result from an immunologic response to a substance to which the client is sensitized.

What is an ampoule?

*Ampoule- A sealed glass drug container that must be broken to withdraw the medication.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

*An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

*Apply a skin protectant to the skin around the incision.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?

*Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. -Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

*Ask to examine the client alone in order to speak to her privately.

What does Aspirate (regarding injections) mean?

*Aspiration-is the process of pulling back on the syringe plunger by applying negative pressure for 5-10 seconds after the needle has been inserted into tissue, but before administration of the medication.

When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?

*Assess the vaginal area.

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

*Assessment of vital signs and respiratory status. -Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation.

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube?

*Avoid crushing sustained-release pellets. -When administering medications through an enteral tube for a tube-fed client, the nurse must avoid crushing sustained-release pellets because keeping them whole ensures their sequential rate of absorption.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

*Avoid unattended baths for the toddler.

The nurse is caring for an older adult client. Which situational assessment findings establish the need for interventions? Select all that apply.

*Bedside table with client's personal items is at the foot of the bed. *Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. *Call light is at top of bed under the pillow.

What is Bisacodyl?

*Bisacodyl- is a rectal suppository used for softening stool.

What are C-I drugs?

*C-I drugs have high abuse potential and are not accepted for medical use.

What drug category indicates fetal risk where the potential benefit might be acceptable despite the risk?

*Category D- Category D drugs, there is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite these potential risks.

A nurse on a medical-surgical unit is administering medications to a client. Which of the following actions should the nurse take?

*Checking the clients mouth to ensure that he has swallowed the medications

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

*Clean the wound from the top to the bottom and from the center to outside. -Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

The nurse is preparing to administer two IV medications. What is the appropriate nursing action?

*Consult a current drug reference book for IV compatibility.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action?

*Contact the health care provider for order clarification. -The nurse should contact the health care provider to verify the order. Bupropion and buspirone are drugs that have look-alike and sound-alike properties but are different in indication.

The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?

*Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.

What is the manufacturer's responsibility during phase IV of a drug trial?

*Continue to monitor the drug's effects while the drug is in general use. -During phase IV of a drug trial, it is the manufacturer's responsibility to continue to monitor the drug's effects while the drug has been placed in general use.

What is Critical Concentration?

*Critical concentration is the concentration a drug must reach in the tissues that respond to the particular drug to cause the desired effect.

What does DEHISCENCE mean?

*Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

*Dehiscence of the wound

A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?

*Deltoid

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?

*Deltoid

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

*Desiccation- Desiccation is localized wound dehydration.

What can cause Yeast infections under breasts?

*Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection.

The nurse is preparing to administer a medication from a multi-dose bottle. The label is torn and soiled but the name of the medication is still readable. What is the nurse's priority action?

*Discard the entire bottle and contents and obtain a new bottle.

Which agency is responsible for the enforcement of controlled substances?

*Drug Enforcement Agency

Necrotic Tissue

*Dry brown or black tissue is necrotic.

Phase I Drug trial-

*During phase I, healthy volunteers are found to test the drug.

A client with a new diagnosis of glaucoma (increased pressure within the eye) has been prescribed a medication that is to be administered by an eye drop. Which action should the nurse perform?

*Ensure that drops of the medication fall onto the client's conjunctival sac. -Eye drops should be applied to the conjunctival sac.

What is Enzyme Induction?

*Enzyme induction is the process by which the presence of a chemical that is biotransformed by a particular enzyme system in the liver causes increased activity of that enzyme system.

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?

*Establish the nurse's role during a disaster. -During a disaster nurses will have multiple roles. In addition to their clinical knowledge, they may be responsible for triage, counseling and various other duties.

What is Evisceration?

*Evisceration- is complete separation of the wound, with protrusion of viscera through the incisional area.

What is Excretion?

*Excretion refers to elimination of a drug from the body.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?

*Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

Infants are vulnerable to injuries related to?

*Falling from the bed is common in infants.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

*Fingers with quick capillary refill *Warm hand *No finger numbness or tingling -The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers.

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse?

*Firmly grasp the gait belt and gently lower the client into bed. -The nurse should ease the client back on the bed to prevent fall and injury.

first degree burn:

*First-degree burns are superficial and may be pinkish or red with no blistering.

Generic Drugs:

*Generic drugs are chemicals produced by companies involved solely in the manufacturing of drugs.

What statement describes a required characteristic of all generic drugs?

*Generic drugs must be therapeutically equivalent and less expensive than trade name drugs.

What is a skin appendage?

*Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis.

What does half-life mean?

*Half-life is the amount of time it takes for 50%of the blood concentration of a drug to be eliminated.

What does Half-Life mean?

*Half-life- is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

*Have a meeting place outside the home in case of fire.

Healing by Secondary Intention-

*Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base.

One of the phases of drug development is the post-marketing surveillance phase. Which activity is carried out during this phase?

*Health care providers report adverse effects to FDA. The post-marketing surveillance phase of drug development encourages health care professionals to report adverse effects of drugs to the FDA using MedWatch.

What does a Hemiplegic Gait mean?

*Hemiplegic gait-includes impaired natural swing at the hip and knee with leg circumduction. The pelvis is often tilted upward on the involved side to permit adequate circumduction. With ambulation, the leg moves forward and then swings back toward the midline in a circular movement.

What would Hyperkalemia labs reflect?

*Hyperkalemia would be reflected by elevated potassium levels (greater than 5.0 mEq/L).

What is Hypoglycemia indicated by?

*Hypoglycemia would be indicated by decreased blood glucose levels.

Which situation accurately describes a recommended guideline when administering oral medications to clients?

*If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

The nurse has given a client an injection. How will the nurse prevent an accidental needle stick?

*Immediately activate the safety needle and place the syringe and needle into a Sharps container.

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

*Impaired Skin Integrity related to open wound -Impaired skin integrity best describes the minor laceration.

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

*Implement a 2-hour repositioning schedule.

3rd Phase of wound healing-

*In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization.

Phase II Drug Trial-

*In phase II, clients with a disease are divided into two groups, and one receives the new drug and the other receives a placebo.

A nurse is preparing to administer medications to an older adult client. The nurse should identify that which of the following physiologic changes can affect the distribution of medications in the older adult client?

*Increased body fat -The nurse should identify that the older adult client experiences an increase in body fat. This physiologic change affects the distribution of medications.

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply.

*Inform the UAP the linens should not be placed on the floor for any reason *Communicate the importance of using proper body mechanics to avoid straining the back

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

*Insert a swab into the wound. *Press and rotate the swab several times over the wound surfaces. *Place the swab in the culture tube when done.

What are intradermal injections?

*Intradermal Injection (ID)- is a shallow or superficial injection of a substance into the dermis, which is located between the epidermis and the hypodermis. *given at a 10-15 degree angle.

What is the Intravenous Route?

*Intravenous (IV) route- is reserved for drugs to be instilled into veins. *120-degree angle.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

*Keep the swab and the inside of the culture tube sterile.

When applying an external heating pad, which prescription from the health care provider would the nurse question?

*Leave heating pad on for 40 to 45 minutes, then off for 2 hours. -The nurse should question the prescription to leave the heating pad on for 40 to 45 minutes, because this is too long and could cause a rebound phenomenon. Using heat for more than 20 to 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage.

What is Liver Injury?

*Liver injury would be reflected by elevated liver enzymes such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT).

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

*Local capillary pressure must be lower than external pressure.

A nurse preparing medication for a client is called away to an emergency. What should the nurse do?

*Lock the medications in a cart and finish them upon return. -Once medications have been prepared the nurse must either stay with the medications or lock them in an area such as the medication cart. -The medications should never be left unattended or placed back in their containers. -Another nurse cannot administer medications that have been prepared by the first nurse.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

*Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

What best describes the nurse's role in disaster preparedness?

*Multiple roles, including triage and the distribution of resources. -Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

Neurotoxicity

*Neurotoxicity, sometimes referred to as central nervous system toxicity, is a drug's ability to harm or poison a nerve cell or nerve tissue. -signs and symptoms of neurotoxicity include drowsiness, auditory and visual disturbances, restlessness, nystagmus, and tonic-clonic seizures. Neurotoxicity can occur after exposure to drugs and other chemicals and gases.

A client is receiving an antineoplastic medication for treatment of breast cancer and begins having tonic-clonic seizure activity. What type of toxicity does the nurse recognize that this client is experiencing?

*Neurotoxicity- Neurotoxicity, sometimes referred to as central nervous system toxicity, is a drug's ability to harm or poison a nerve cell or nerve tissue.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

*Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement. -With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration.

The nurse is transcribing physician orders for a client with pneumonia who has been admitted to the hospital. Why should the physician order the medications using the generic name instead of a brand name?

*Numerous brand names may exist for the same drug, sothe generic drug should be ordered.

What does Parenteral mean?

*Parenteral Meds- Parenteral drugs are most commonly administered as an injection without entering the mouth, stomach, intestines, rectum or respiratory tract. The parenteral route allows medications to be directly absorbed into the body quickly and more predictably.

What does Peak Level mean?

*Peak level- is the highest plasma concentration.

What is Pharmacodynamics?

*Pharmacodynamics is one topic discussed in pharmacotherapeutics that addresses what the drug does to the body.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

*Placing the client in a bed with a bed alarm.

The chemotherapy client has been admitted for thrombocytopenia. Which blood product will the nurse anticipate administering?

*Platelets

What is the primary role of the nurse in the care of clients who experience domestic violence?

*Providing prompt recognition of the potential or actual threat to safety.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

*Pull the fire alarm lever.

What does Purulent drainage look like?

*Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.

The nurse is preparing a medication that is new to the market and cannot be found in the nurse's drug guide. How should the nurse obtain the most reliable information about this medication?

*Read the package insert. -The most reliable information about the drug can be found on the package insert supplied by the manufacturer because it was prepared according to strict Food and Drug Administration (FDA) regulations.

What does Reconstitution mean?

*Reconstitution- is the process of adding liquid, known as diluent, to a powdered substance.

What is a Refilled Cartridge?

*Refilled Cartridge- A sealed glass cylinder of parenteral medication with an attached needle.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

*Remove the client from the room.

Which action is the best example of a nurse donning/removing protective equipment properly?

*Removing respirator after leaving client's room.

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case?

*Return the medication to the medication cart or medication room.

A nurse is preparing to administer a scheduled dose of enteric-coated ASA to a client who has a history of angina. When preparing the medication, the nurse is careful to check the five rights of medication administration. The five rights include which of the following?

*Right time -The five rights consist of the right client, right drug, right dose, right route and right time.

What is ringworm caused by?

*Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

*Risk for Poisoning related to poor eyesight and the inability to read medication labels.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

*Rotate the swab several times over the wound surface to obtain an adequate specimen. -The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection.

What does S/P mean?

*S/P- Status Post (After).

What does sanguineous drainage look like?

*Sanguineous drainage consists of red blood cells and looks like blood.

Which schedule drugs have high abuse potential and no accepted medical use?

*Schedule I- Schedule I drugs have a high abuse potential and no accepted medical use.

Schedule II Drugs-

*Schedule II drugs have high abuse potential with severe dependence liability.

Schedule III Drugs-

*Schedule III medications have less abuse potential than schedule II drugs and moderate dependence liability.

Schedule IV Drugs-

*Schedule IV drugs have less abuse potential that schedule III and limited dependence liability.

Second degree burns:

*Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters.

What does Serous drainage look like?

*Serous drainage is a clear drainage consisting of the serous portion of the blood.

When does Shearing occur?

*Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

What are common sites used for INTRADERMAL INJECTIONS?

*Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula.

What is Slough Tissue?

*Slough- Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green.

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

*Social pressure- As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

*Stage II- A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater.

Stage III

*Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

Stage IV Pressure Ulcer-

*Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

Stage IV Ulcer

*Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor.

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

*Stop removing staples and inform the surgeon.

A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?

*Stop the infusion.

A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action?

*Stop the sitz bath, call for help, and help the client to the toilet to sit down. -if the client complains of feeling light-headed or dizzy during a sitz bath: Stop the sitz bath. Do not attempt to ambulate the client alone. Use call light to summon help. Let the client sit on the toilet until feeling subsides or help has arrived to assist the client back to bed.

What is the Subcutaneous Route?

*Subcutaneous Route- is reserved for drugs to be injected beneath the skin but above the muscle. -The abdomen and anterior aspect of the thigh are common injection site.

Subcutaneous Injection

*Subcutaneous Tissue (Fat) under the skin. Either at a 90* angle- if pinching 2in of skin. 45* angle if pinching 1in of skin.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

*Subcutaneous tissue- The subcutaneous tissue is the skin layer that is responsible for storing fat for energy.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

*Tactfully request the provider to input the order into the computerized provider order system.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

*Take the restraints off, stay with her, and talk gently to her.

The nurse takes an 8 a.m. medication to the patient and properly identifies her. The patient asks the nurse to leave the medication on the bedside table and states that she will take it with breakfast when it comes. What is the best response to this request?

*Tell her that you cannot leave the medication but will return with it when breakfast arrives.

A patient refuses to take her noon medication, saying that she does not need it. Which of the following would be the best response?

*Tell her that you will return the medications to the cart but would like to discuss her reasons for refusing to take the medications.

Many drugs that reach the developing fetus or embryo can cause death or congenital defects, which can include skeletal and limb abnormalities, central nervous system alterations, heart defects, and the like. What is the name of the adverse reaction that can cause birth defects?

*Teratogenicity- Teratogenicity is when drugs that reach the developing fetus or embryo cause death or congenital defects, which can include skeletal and limb abnormalities, central nervous system alterations, heart defects, and the like.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have?

*Tetanus, infection, wound care, and pain control.

Hemovac Drain Chambers-

*The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours.

A nurse is preparing to administer medication to a client. Which of the following client identifiers should the nurse use to ensure safe practice?

*The barcode on the client's wristband

The nurse is reviewing a prescription for a medication with a client. On the prescription, the nurse read "DAW." What should the nurse teach the client?

*The brand name of the drug must be dispensed.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

*The client is aware of spatial relationships to avoid the table. -The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes.

The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response?

*The client will continue to grow rapidly and will refine both gross and fine motor skills.

Stages of infection:

*The correct sequence of the stages of infection are (1) incubation period (the period between exposure to an infection and the appearance of the first symptoms.), (2) prodromal stage (signs & symptoms are present/more severe), (3) full stage of illness, and (4) convalescent period (healing period).

The nurse correlates the metric system as the most accurate method utilized to administer medications for which reason?

*The dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements.

Epidermis-

*The epidermis is the outer layer that protects the body with a waterproof layer of cells.

Which should be documented by the nurse?

*The fact that sterile technique was used for a given procedure.

Muscle Layer-

*The muscle layer moves the skeleton.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

*The nurse details the client's response and the examination and treatment of the client after the incident.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

*The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

*The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. -A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist.

A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall?

*The nurse should gently slide the client down his or her body to the floor.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

*The nurse should question the client about the source of the bruises.

A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?

*The nurse will have the client rate pain on the pain scale of 1 to 10 and proceed accordingly.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

*The nurse works outward from the wound in lines parallel to it. -A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

*The report provides a detailed and objective account of the circumstances before, during, and after the event.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

*The status of the client's tetanus immunization.

What is a Ventrogluteal Site?

*The ventrogluteal site is a large muscular injection site that provides a location with the capacity for depositing and absorbing the drug.

Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?

*The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.

What does Therapeutic Range mean?

*Therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity.

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

*Therapeutic range.

What does Thrombocytopenia mean?

*Thrombocytopenia- is a condition in which you have a low blood platelet count.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

*Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

What is Timolol?

*Timolol- is an eye drop used to treat glaucoma.

What does Trough Level mean?

*Trough level- is the point when the drug is at the lowest concentration.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

*True -A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

What is a Turbo-Inhaler?

*Turbo-Inhaler-which is a propeller-driven device that spins and suspends a finely powdered medication. Turbo-inhaler- has propellers that get activated during inhalation.

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.

What is Undermining?

*Undermining-is tissue erosion from underneath intact skin at the wound edge.

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?

*Use clean technique instead of sterile technique if the wound is closed. -When the solution from the wound turns clear, the irrigation should be discontinued.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

*Use protective sporting equipment.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

*Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown -Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters.

A client requests more medication for pain at the surgical site rated 8 out of 10. There is a prn prescription for 10 mg PO of oxycodone for pain greater than 6 out of 10 on the pain scale. Which action should the nurse take first?

*Verify clients name and date of birth. -the first step is to have the client verify name and date of birth.

What is a Vial?

*Vial- A glass or plastic container of parental medication with a self-sealing rubber stopper.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

*When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

How to remove gloves properly?

*When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist and the glove is pulled off and inverted.

What is healing by Primary Intention?

*Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

Healing by Primary Intention-

*Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner.

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?

*a canister containing medication that is released when the container is compressed. -A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

*a client sitting in a chair who slides down.

To which client would the nurse be most likely to administer a p.r.n. medication?

*a client who is reporting pain near the surgical site.

What is a Jackson-Pratt (JP) Drain?

*a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites also called a JP drain.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

*a critical care client -Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.

The nurse is caring for a client receiving an aminoglycoside (antibiotic) that can be nephrotoxic. Which will alert the nurse that the client may be experiencing nephrotoxicity?

*a decrease in urine output

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

*a surgical incision with sutured approximated edges.

Which clients would be considered at risk for skin alterations? Select all that apply.

*a teenager with multiple body piercings *a client receiving radiation therapy *a client with diabetes

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

*a transparent film -Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms.

A client is administered an oral contraceptive. What is the process that occurs between the time the drug enters the body and the time it enters the bloodstream?

*absorption- Absorption is the process that occurs from the time the drug enters the body to the time it enters the bloodstream to be circulated.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

*administration of an antipsychotic agent to alter the client's behavior. -Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement.

The nurse should have basic knowledge of drug classifications in order to administer medications safely to clients. What drug information is instrumental in determining nursing actions following drug administration?

*adverse effects -Becoming familiar with classifications of medications helps the nurse to recognize possible adverse effects clients may experience, providing a basis for implementing appropriate nursing actions should undesirable effects occur. The route of administration, body system involved, and protocols are more important to know before medication administration.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

*airborne precautions *droplet precautions *contact precautions The CDC has three general precautions: contact, droplet, and airborne.

A client's risk for the development of a pressure injury is most likely due to which lab result?

*albumin 2.5 mg/dL -An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

*an 84-year-old male with four recent driving violations.

A client is being seen in the emergency department for a sprained ankle and is given a drug to relieve pain. When a second dose of the pain medication is given, the client develops redness of the skin, itching, and swelling at the site of injection of the drug. The most likely cause of this response is:

*an allergic response.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

*an obese woman with a history of type 1 diabetes. -Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

*applying sterile dressings with normal saline over the protruding organs and tissue. -The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

The nurse is administering an intramuscular injection to a client. Which action made by the nurse could assess whether the needle is in the client's blood vessel or not?

*aspirating for a blood return. -Aspirating for a blood return is correct, as this will determine if the needle is in the blood vessel.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

*automobile accidents. -Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

*bed trapeze- a trapeze bar is a handgrip suspended from a frame near the head of the bed. A client can grasp the bar with one or both hands and raise the trunk from the bed. The trapeze makes moving and turning considerably easier for many clients and facilitates transfers into and out of bed.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

*cleanse with a new gauze for each stroke. -When cleansing a wound, the nurse should use a new gauze or swab on each downward stroke of the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles, beginning in the center and working toward the outside.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

*corticosteroids -Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. **Corticosteroids decrease the inflammatory process, which may delay healing.

What is a benefit of regular exercise over time?

*decreased heart rate

A 38-year-old client is obese and has abscesses around the inner thigh muscles. The client is receiving IV antibiotics, but no improvement has been seen. The client questions the nurse about the most likely cause for the drug therapy failure. The nurse explains that the:

*distribution of the drug to the area of the abscesses is impaired. -Abscess (pus-filled) pockets surrounded by normal tissue have limited blood supply, especially to the center. The antibiotic cannot penetrate the abscess due to the limited blood supply to these areas.

A client's most recent laboratory result indicate an elevated potassium level. What drug in this client's medication regimen should the care team consider discontinuing?

*diuretic- Elevated potassium levels can result from the use of certain diuretics.

A full-thickness or third-degree burn develops a leathery covering called a(an):

*eschar -The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

*evisceration- Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

Toddlers are vulnerable to injuries related to?

*falling from staircases is a common injury among toddlers

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

*figure-of-eight turn -A figure-of-eight turn is used for joints like the elbows and knees.

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

*fill out an incident report, with the goal of preventing a similar event in the future.

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

*foot drop. -A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Foot drop is a contracture in which the foot is fixed in plantar flexion.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider?

*foul-smelling drainage that is grayish in color. -Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider.

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. -Fingernails should be less than ¼-in. (0.625-cm) long.

When moving a client up in bed with the assistance of another caregiver, the nurse should:

*have the client fold the arms across the chest.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing?

*hydrocolloid dressing- Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing.

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

*intradermal-is injecting the drug between the layers of the skin.

A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique?

*intramuscular

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

*keeping medications in clearly labeled containers

Drug excretion occurs mainly in which organ?

*kidneys- Drug excretion is removal of the drug from the body, which occurs mainly through the kidneys.

The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed?

*miconazole- The nurse anticipates that miconazole, a vaginal cream, will be prescribed for a yeast infection.

When administering heparin subcutaneously, the nurse should?

*never aspirate.

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

*noncommunicable disease. -A noncommunicable disease is caused by food or environmental toxin.

A client with a rare genetic disorder is prescribed a medication specific to this disorder. What is the name given to drugs manufactured by companies that receive tax benefits to invest in these drugs?

*orphan drugs- The 1982 Orphan Drug Act provides certain tax benefits to companies that invest in drugs useful in the diagnosis, treatment, or prevention of rare diseases, termed orphan drugs.

Which drug type has been discovered but not manufactured by any drug company?

*orphan-Orphan drugs have been discovered but are not financially viable and therefore are not being manufactured by any drug company.

A nurse is reading an article that describes predictable differences in the effects of drugs in people of particular culture backgrounds due to their genetic makeup. The nurse is reading about:

*pharmacogenomics

What is the branch of pharmacology that uses drugs to treat, prevent, and diagnose disease?

*pharmacotherapeutics-

Which action describes buccal (Cheek) medication administration?

*placing a medication underneath the upper lip or in the side of the mouth. -Buccal medication is not chewed, swallowed, or placed under the tongue.

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.

*provide incontinent care every 2 hours and as needed *turn the client every 2 hours when the client is in bed *encourage the client to take fluids every 2 hours

The nurse is caring for an older adult and is reviewing the normal age-related changes that occur in this group of clients and realizes that such changes extend the half-life of drugs. What is the physiologic change that causes this to occur?

*reduced oxidation in phase I of hepatic metabolism -Aging affects the efficiency of both phases of metabolic activity but tends to alter phase I more than phase II reactions. Because drug metabolism is slowed by reduced oxidation in phase I, drug blood levels are higher, and drug half-lives are extended in older adults.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

*removing clutter from the floor *placing nightlights in the bathroom and hallways *moving the bedroom to the ground floor

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

*removing dead or infected tissue to promote wound healing.

The nurse is reviewing the laboratory test results of a client receiving drug therapy. What would the nurse suspect if the results reveal an elevation in the blood urea nitrogen level and creatinine concentration?

*renal injury-Renal injury is reflected by elevated blood urea nitrogen and creatinine concentration.

Which best describes the proliferative phase, the third phase of the wound healing process?

*reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization. -In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization.

What would be considered a "right" of drug administration? Select all that apply.

*right drug *right documentation *right dose *right client

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

*secondary intention- Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base.

Penicillin causes bacterial cell death without disrupting normal human cell functioning. This is an example of:

*selective toxicity.- Penicillin affecting only bacterial cells is an example of selective toxicity, the property of a drug that affects only systems found in foreign cells without affecting healthy human cells

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

*serosanguineous

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document?

*serosanguineous- Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink.

A client, prescribed a drug that has an exceptionally narrow margin of safety, should be educated about the need for what intervention?

*serum drug level monitoring -Measuring serum drug levels is useful when drugs with a narrow margin of safety are given because their therapeutic doses are close to their toxic doses.

Many drugs that reach the developing fetus or embryo can cause death or congenital defects. What are examples of congenital defects? Select all that apply.

*skeletal and limb abnormalities *central nervous system alterations *heart defects

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

*stage IV- Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor.

The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client?

*supine -To best facilitate instillation of nasal medication via a dropper, and to ensure that the drug is administered into the place where its effects are desired, the nurse will place the client in supine position.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

*supine- Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?

*temporary application of devices that reduce the client's ability to move arms.

Drugs known to cause birth defects are called?

*teratogenic.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

*to apply sunscreen when exposed to ultraviolet rays.

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal?

*to determine the extent to which the client responded to the drugs.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

*to provide drainage for bile. -A T-tube is used to drain bile, such as after a cholecystectomy (removal of the gallbladder).

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

*trochanter rolls- Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

*use pillows to maintain a side-lying position as needed.

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?

*when the client has disorders that affect the absorption of medications. -Intravenous administration may be chosen when clients have disorders, such as severe burns, that affect the absorption and metabolism of medications. IV therapy is also used in an emergency when a quick response is needed.

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

*within normal limits- A normal white blood cell count is 5,000 to 10,000 cells/mm3.

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

-"These barriers help prevent the transmission of infection to you or other people." *Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?

-Incentivizing health care workers to utilize hand hygiene. *Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene.

What is the Prodromal Stage?

-Promdromal Stage- is the most infectious. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads.

How is Hepatitis C transmitted?

-There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client?

-Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

What does Causative mean?

-a biologic pathogen that causes a disease, such as a virus.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

-airborne precautions -droplet precautions -contact precautions

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

-noncommunicable disease. A noncommunicable disease is caused by food or environmental toxin.

A nurse is providing wound care for a client who has a pressure inury on the right buttock. Place in order the nursing interventions the nurse should perform during this dressing change. Use all options.

1. Give pain medication. 2. Use nonsterile gloves. 3. Remove old dressing. 4. Apply sterile gloves. 5. Cleanse the wound with normal saline. 6. Apply wound covering.

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

1. Place the sterile glove package on a clean, dry surface at or above your waist. 2. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it. 3. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 4. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 5. 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. 6. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 7. Carefully insert dominant hand palm up into the glove and pull it on.

A student nurse is attending a clinical rotation in the perioperative department and will be allowed to scrub in to observe. What observation made by the clinical instructor requires intervention before the student is allowed to attend the rotation? Select all that apply.

1. rings on finger 2. artificial nails with intact clear nail polish 3. red nail polish *Artificial nails and nail polish are never appropriate and may introduce infection into a surgical wound. Nail polish may chip and enter into surgical wounds. Rings should be removed because they are a source of contamination from bacteria and other pathogens.

Which client would the nurse consider the most infectious?

A client who is in the prodromal stage -Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the client often is unaware of being contagious. As a result, the infection spreads.

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

A nurse's gloves became soiled while providing morning care for a client. Which action best demonstrates that the nurse applied principles of infection control?

After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.

What is Survival adaptation?

An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae.

The nurse is providing care for a client with varicella. What action should the nurse perform?

Ensure the client is housed in a negative pressure room.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Hand hygiene is needed after contact with objects near the client.

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. *Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination.

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice?

It is appropriate to use clean technique during this procedure.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips.

What does Opportunistic Infection mean?

Opportunistic infections (OIs) are infections that occur more often or are more severe in people with weakened immune systems than in people with healthy immune systems. People with weakened immune systems include people living with HIV. OIs are caused by a variety of germs (viruses, bacteria, fungi, and parasites). OI-causing germs spread in a variety of ways, for example in the air, in body fluids, or in contaminated food or water. Here are examples of some of the most common OIs in people with HIV in the United States: Herpes simplex virus (HSV) infection—a viral infection that can cause painful cold sores in or around the mouth, or painful ulcers on or around the genitals or anus -Salmonella infection—a bacterial infection that affects the intestines (the gut) -Candidiasis (or thrush)—a fungal infection of the mouth, bronchi, trachea, lungs, esophagus, or vagina -Toxoplasmosis—a parasitic infection that can affect the brain

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

Place a surgical mask on the client and transport to the CT department at the specified time.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?

Review the current infection control protocols.

What is Surgical Asepsis?

Surgical asepsis (sterile technique)- is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Surgical asepsis- Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter.

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

Survival adaptation

What is the Incubation Period?

The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

The nurse places the client in a private room with monitored negative air pressure.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?

The nurse removes her gown and then removes her gloves.

Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?

The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. *the nurse must wash at last 1 in (2.5 cm) above the area of contamination to properly performed hand hygiene. The nurse should use warm to hot water to wash hands.

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

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?

When hands are visibly soiled

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

a rash related to a yeast infection.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman *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

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?

contact

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

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown and gloves

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

hand washing

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

perform hand hygiene before and after entering the client's room

Which nursing action demonstrates safe injection practice?

use sterile single-use disposable syringes for each injection