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Use Tracheostomy covers when outdoors - covers protect the client's airway from cold air, dust and other airborne particles a home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. the client has recently developed diarrhea. which of the following findings should the nurse identify as a possible cause of the diarrhea? the client's caregiver washes out the feeding bag with warm water once every 24hr. - feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24hrs to prevent bacteria contamination. * cold formulas cause gastric cramping so it should be at room temp *diarrhea is most likely to dev. with fast installation *tubing should be flushed with water before and after administering meds to prevent clogging a nurse is talking with an older adult client who is contemplating retirement. the client states "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." which of the following responses should the nurse make? "lets talk about how the change in your job status will affect you." - therapeutic response because the nurse is encouraging the client to verbalize feelings a nurse is assessing a client who reports increased pain following pt. which of the following questions should the nurse ask when assessing the quality of the client's pain? "is your pain sharp or dull?" - asking whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. *constant or intermittent pain: determines onset, duration and pattern of pain *scale of 0-10: determines intensity of pain *pain radiates: determines pain location a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. which of the following actions should the nurse take? Reassure the client that this is an expected response to grief. - during the anger stage of the psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. a nurse on a med-surge unit is caring for a client who has a new prescription for wrist restraints. which of the following actions should the nurse take? pad the client's wrist before applying the restraint. - the use of restraints without padding can abrade the client's skin and cause injury. *Client's circulation, ROM, vital signs, and overall status should be evaluated every 15 min after initial application of restraints. *restraints should be repositioned at least every 2 hours and assess needs for hygiene and toileting. *ties should be tied to bed frame a nurse is performing home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol? the client uses non acetone nail polish remover *should use cotton blanket instead of wool to prevent static electricity *should store oxygen in upright position *should inspect oxygen equipment daily a nurse is caring for a client who has a respiratory infection. which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? Apply intermittent suction when withdrawing the catheter *should insert catheter while the client is inhaling to avoid inserting into the esophagus *discard catheter after use to eliminate the risk of pathogens *hold suction with dominant hand after donning a sterile glove. a nurse is preparing to administer enoxaparin subQ to a client. which of the following actions should she take? Administer the med with needle at 45 degree angle *enoxaparin should be administered into abdomen at least 2cm from the umbilicus *Z track method (pulling skin taut) is done for IM *do not massage the site after injecting an anticoagulant due to risk for bruising a nurse is preparing an education program for staff about advocacy. which of the following info should the nurse include? advocacy ensures clients' safety, health and rights *accountability: the responsibility of nurse to explain their own actions to their clients and employers *fidelity: an agreement by nurses to follow through with promises made to client *justice: fairness in client care delivery, including distribution of resources and care. a nurse is administering an otic med to an older adult client. which of the following actions should the nurse take to ensure that the med reaches the inner ear? press gently on the tragus of the client's ear. *inserting cotton into meatus of canal could damage ear. if needed, place cotton on outer portion of ear canal and do not push inwards *for adult client, move the auricle upward and backward or upward and outward to straighten canal *client should lie on one side with the ear that received med facing upward for 2-5 min a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client? use bed exit alarm system - those with dementia requires assistance when exiting bed as they might forget to ask for help. they are also at risk for falling. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? make sure the client wears mask when outside her room if there is construction in the area *protective environment requires at least 12 air exchanges per hour *be placed in a private room that provides positive-pressure airflow *nurse does not need a n95 mask for a protective environment The nurse is providing discharge instructions to a client who will be using a walker. which statement indicates an understanding of the teaching? "I will hire someone to trim the trees that hangs low over the stairs of my porch." *extension cords should be securely fastened to the floor and should run along the edge of the all to avoid risk for tripping *frequently used items such as clocks and glasses should be within reach to prevent them from getting up especially at night *using rugs would increase their risk for falls by tripping or slipping. a nurse is planning to insert a peripheral IV catheter for an older adult client. which actions should she take? place the client's arm in a dependent position *insert catheter at 10-30 deg angle. for older client, an angle of 10-15 deg is preferred because veins are closer to skin surface as they age. *clip excess hair from IV site but avoid shaving as that can cause breaks and cuts which increases risk of infection *nurse should avoid using fragile veins of an older adult's hands because loss of subQ tissue allows veins to roll away from needle. having a catheter on hand also interferes with ADLs a nurse is planning care for a client who has had a stoke, resulting in aphasia and dysphagia. the AP can: - assist partial bed they cannot: a nurse is performing a skin assessment for a client who expresses concern about skin cancer. which findings should the nurse identify as potential indication of skin malignancy? a mole with an
asymmetrical appearance *lesions with uniform pigmentations is not bc it is uniform *petechiae are capillaries that burst under skin and are not expected to be malignant *papules are solid elevations less than 1cm in size; not malignant The nurse is caring for a client who has sodium 125meq/l. which findings should nurse expect? abdominal cramping *hyperkalemia: numbness in extremities *hyponatremia and hypovolemia: tachycardia *hypomagnesemia and hypocalcemia: positive ckvostek's sign a nurse is preparing a change of shift report. which of the following tools or documents should the nurse use to communicate continuity of care? SBAR *Critical pathway: an inter-professional approach to planning all phases of client care *transfer report: when client is moving from one healthcare area/facility to another *MAR: to document med administration "The nurse is admitting a client who is having an exacerbation of heart failure. in planning this client's care, when should the nurse initiate discharge planning? During the admission process *the client does not have to be stable: Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability. *Team conferences facilitate discharge planning, but they are not essential for initiating the planning process. *The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs. a nurse is educating a client who has a terminal illness about declining resuscitation in a living will. the client asks, "what would happen if I arrive at the emergency department and I have difficulty breathing?" which of the following responses should the nurse make? "We would give you oxygen through a tube in your nose." *"We would consult the person appointed by your health care proxy to make decisions.": The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's health care proxy to make decisions about the client's care. *"You would be unable to change your previous wishes about your care.": Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. *"We would insert a breathing tube while we evaluate your condition.": Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take when inserting the NG tube? have the client take sips of water to promote insertion into esophagus *The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration. *The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. *The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client. a nurse in a long-term care facility is caring for a client who dies during the nurse's shift. identify the sequence in which the nurse should perform the following steps: 1 - obtain pronouncement of death from the provider 2- remove tubes and lines 3- wash the body 4- ask the family members if they want to see the body 5 - place a name tag on the body a nurse is providing discharge teaching to a client about self-administering heparin. which of the following instructions should the nurse include in the teaching? administer the medication into the abdomen *The nurse should instruct the client to insert the needle at a 45° to 90° angle to administer the medication into the subcutaneous tissue. *The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. *The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising. a nurse is caring for a client who asks about the purpose of advanced directives. which of the following statements should the nurse make? "they indicate the form of treatment a client is willing to accept in the event of a serious illness." - Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness. a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs? Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety. Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall. a nurse is assessing a client who has required bed rest for the month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? Calf swelling *Urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles. *A client who requires bed rest can develop postural hypotension, which is a drop in blood pressure when the client moves from a lying to a sitting position. The nurse should also assess the client for an increase in pulse rate and dizziness. *A decrease in bowel sounds reflects slowed peristalsis. Constipation is a common complication of immobility. a nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has a fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful? A. increase in hematocrit C. decrease in heart rate *Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. *Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range. a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include? B. CORRECT a. The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter. c. The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale. d. Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen. a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? Examine personal values about the issue a nurse is caring for a client who has a terminal illness and is approaching death. the client is SOB and has noisy respirations from secretions in their
airways. which of the following actions should the nurse take? A. correct b. The nurse should administer antiemetics for clients who are experiencing nausea or vomiting. However, this is not the correct action to take when assisting a client who is experiencing respiratory difficulty at the end of life. c. The nurse should provide frequent oral care in order to keep the client's mouth moist and provide comfort. d. Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening windows is more comfortable for a client who is dying and will decrease air hunger. a nurse receives
report about a client who has 0.9% nacl infusing IV at 125ml/hr. when the nurse performs the initial assessment, he notes that the client has only received 80ml over the last 2 hours. which actions should the nurse take first? D. correct a. The nurse should reposition the client to help improve the flow rate; however, there is another action the nurse should take first. b. The nurse should document the client's IV intake in the medical record accurately to help the team prevent or correct fluid imbalances; however, there is another action the nurse should take first. c. The nurse should request a new IV fluid prescription to compensate for lost fluid intake; however, there is another action the nurse should take first. a nurse is preparing to administer an injection of an opioid med to a client. she draws out 1ml from the 2ml vial. which actions should she take? A. correct b. Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. c. The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. d. The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act. a nurse us caring for a group of clients. which of the following should she take to prevent the spread of infection? B. Correct a. The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission. c. People transmit HIV mainly by blood and sexual activity; therefore, a client who is HIV-positive does not require disposable plates and utensils. Standard precautions are sufficient. d. The nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to micro-organisms.
a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. which action should the nurse take? C. correct a. The nurse should place the client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves. b. The nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure. d. The nurse should set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment. a nurse is using an open irrigation technique to irrigate a client's indwelling catheter. which actions should she take? C. correct a. For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter. b. Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. d. The nurse should use a 30- to 50-mL syringe to perform open irrigation. a nurse is caring for a client who has pharyngeal diphtheria. which type of transmission precautions should the nurse initiate? B. correct a. Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections. c. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. d. Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others. The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock.
the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 minutes and to report back in 1 hour. which actions should the nurse take next? D. correct a. The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. b. The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. c. The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority. a nurse is reviewing a client's fluid and electrolyte status. which finding should the nurse report to provider? D. correct normal values: Creatinine:
Sodium: potassium: 3.5 - 5 meq/l a nurse is caring for a client who is postoperative. when the nurse changes her dressings, she complains of pain. which of the following interventions is the nurse's priority? D. correct a. Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client's anxiety about the procedure. However, there is another intervention that is the priority. b. Educating the client about the importance of the dressing change is important because understanding the rationale for the procedure can help the client relax. However, there is another intervention that is the priority. c. Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority. a nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which type of transmission precaution should the nurse take? D. correct a. Clients who have a compromised immune system require a protective environment. b. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. c. Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which action should the nurse take? Stand close to the cabinet when lifting it. - This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. a nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. which of the types of dressing should the nurse use? D.
correct a. Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. b. Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. c. Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. a nurse is evaluating a client's use of a cane. which action should the nurse identify as an indication of correct use? C. correct a. The top of the cane should be parallel to the client's greater trochanter. b. To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. d. The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg. a nurse manager is preparing to review medication documentation with a group of new nurses. which should the manager include in the teaching? "Use the complete name of the medication magnesium sulfate." - The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. which pain therapy is contraindicated for a patient with herpes zoster? D. correct a. Biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique. b. Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy. c. Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy. a postoperative client is verbalizing pain as a 2. which statement is an indication that the client understands the postoperative teaching she received about pain management? "It might help me to listen to music while I'm lying in bed." - Listening to music is an effective nonpharmacological intervention for the management of mild pain. a nurse is assessing four adult clients. which of the following physical assessment techniques should she use? Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. - The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading. a nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and then leaves. the client declines discussing any concerns. what should the nurse say? "I am available to talk if you should change your mind." - When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client. Which patient condition warrants airborne precautions select all that apply?Airborne precautions are required to protect against airborne transmission of infectious agents. Diseases requiring airborne precautions include, but are not limited to: Measles, Severe Acute Respiratory Syndrome (SARS), Varicella (chickenpox), and Mycobacterium tuberculosis.
Which of the following diseases require the use of airborne precautions quizlet?Diseases that require airborne precautions include tuberculosis and chicken pox. Patients who are diagnosed with this type of communicable disease must be treated with special care.
Which client requires transmission based precautions?Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission.
What precaution should nurses take to prevent an airborne infection?Wear an Appropriate Respirator
Due to the decreased size of the infectious agents in airborne illnesses, such as spores or dried, aerosolized nuclei, a higher-level respirator is needed to prevent their inhalation.
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