exit pdf mj Flashcards
- A nurse is caring for a client who is 2 days following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression to independence and mobility for the client?
A. Keep loose absorbent dressing around incision site.
B. Encourage the client to use the overhead trapeze.
C. Caution the client to avoid a prone position while in bed.
D. Maintain abduction of the client’s limb with a pillow.
B. Encourage the client to use the overhead trapeze.
A nurse at a pediatric clinic is checking the vital signs of a 2 month old infant prior to administering immunization. The nurse should recognize respiratory rate is 30/min. This indicates that the respiratory rate is?
A. Respiratory rate is a manifestation of respiratory infection
B. Within the expected range
C. Result of cold stress
D. Manifestation respiration depression
B. Within the expected range
A nurse is reinforcing discharge teaching with a family of a client who has dependent personality disorder. What action should the nurse take?
Encourage the client to be assertive
A charge nurse in the long-term care facility notices the smell of alcohol from one of the nurse’s breath. Which oc the following actions should the nurse take first?
A. Assign the client to the remaining staff
B. Remove the nurse from the client care area
C. Document objective findings from the situation
D. Call the supervisor to ask for another nurse
B. Remove the nurse from the client care area
A nurse in a clinic is collecting data with a client who had a vaginal birth 6 weeks ago. Which of the following findings should the nurse expect?
A. Increase growth of fine body hair
B. Fundus is halfway palpable
C. White Blood Cells are elevated
D. Reported Lochia Alba
D. Reported Lochia Alba
A nurse is supervising an assistive personnel. Which of the following actions by the AP indicates an effective use of client care materials?
A. Wears clean gloves when assisting client with oral care
B. Empty sharp container when it is full
C. Wearing an N95 when bathing a client who has C-Diff
D. Returns unopened food items from the clients tray to the client
A. Wears clean gloves when assisting client with oral care
A nurse is preparing to administer spironolactone and lisinopril to a client who reports anxiety, dyspnea, and weakness of the leg. Which of the following actions should the nurse take first?
A. Withhold the prescribed medication
B. Document the client’s manifestations
C. Administer insulin per facility rules
D. Call the provider
A. Withhold the prescribed medication
A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states, “I’m thinking of stopping the treatment.” Which of the following responses should the nurse make?
A. “Why do you think that would be a good choice?”
B. “Tell me more about what you are thinking.”
C. “I would feel the same way if I were you.”
D. “You’ll be cancer-free after you complete your treatment.”
B. “Tell me more about what you are thinking.”
The nurse is caring for a client who reports having a decreased in fetal movement following an external cephalic version 6 hours ago. The nurse identifies the fetus in Right Occipital Anterior position. Where should the nurse place the fetal heart monitor?
The nurse should put the fetal heart rate monitor above the umbilicus and to the right of thew abdomen.
A nurse is RT with a client who is 35 weeks gestation who will undergo a contraction stress test. WOTF information should the nurse include in the teaching?
A. We will apply warm, moist cloths to your breasts
B. We will perform internal monitoring of your baby
C. You should expect the test to take 2 hours
D. You will lie flat on your back for the test
D. You will lie flat on your back for the test
A nurse is collecting data from a client who represents the facility and who reports vomiting. WOTF findings indicate that the client is experiencing Fluid Volume deficit?
A. Orthostatic hypotension
B. Brisk Capillary Refill
C. Bradycardia
D. Polyuria
A. Orthostatic hypotension
A nurse is reinforcing dietary teaching for a client who is 37 weeks gestation and has gestational hypertension. WOTF foods should the nurse recommend? (SATA)
A. Sourkauret
B. Raw apple
C. Ham
B. Cooked carrots
E. Lettuce salad
B. Raw apple, B. Cooked carrots
A client who has cancer is being discharged to home with hospice services. The client has a
prescription for oxycodone for pain control. WOTF medications should the nurse remind the client to take regularly to prevent a common adverse effect of this medication?
A. Ranitidine
B. Docusate Sodium
C. Lorazepam
D. Gabapentin
B. Docusate Sodium
A nurse is caring for an adolescent client who has been hospitalized for several weeks. WOTF actions should the nurse take relative to the client’s developmental stage?
A. Arrange for uninterrupted visitations with friends
B. Invite the patient’s parents to stay overnight in the daughter’s room
C. Encourage the client’s friends to being favorite books to read
D. Provide the client with a variety of jigsaw puzzles
A. Arrange for uninterrupted visitations with friends
A nurse is RT with a parent of a preschool age child who has a new diagnosis of varicella. WOTF statements indicate an understanding of the teaching?
A. I will give my child a bubble-bath every day
B. I will apply an antipruritic cream to my child’s skin
C. I will give my child an antibiotic for 10 days
D. I will apply alcohol to my child’s skin to dry out the lesions
B. I will apply an antipruritic cream to my child’s skin
A nurse is caring for a client who is experiencing urge incontinence and limited dexterity. WOTF
actions should the nurse take?
A. Establishing urinary habit program
B. Instruct the client about bladder compression
C. Instruct the client about self catheterization
D. Limit daily fluid intake
A. Establishing urinary habit program
A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. WOTF information should the nurse include in the teaching?
A. You will feel pressure when I inflate the catheter balloon
B. You cannot drink fluids for hour hours after the procedure
C. You will have a leg bag to collect the urine
D. You will need to urinate before
D. You will need to urinate before
A nurse at a long-term care facility is reviewing the PoC of a client who has a prescription for mitten restraints. WOTF tasks does the nurse assign to the assistive personnel?
A. Instruct the client’s family about the purpose of the restraints
B. Determine the circulatory status of the affected extremity every 2 hours
C. Evaluate the need for the client to remain in restraints
D. Assist with ROM of the hand
D. Assist with ROM of the hand
A nurse is RT with a client who has primary open-angle glaucoma and a new prescription for Timolol eye drops. WOTF statements by the client indicates an understanding of the teaching?
This medication will darken the color of my eyes
I should check my heart rate while taking this medication
I should take iron supplements with this medication
This medication will improve my vision
I should check my heart rate while taking this medication
A nurse is obtaining a health history from a client who wants to take oral contraceptives. WOTF
findings is the nurse’s priority?
Irregular periods
Smoking
Asthma
Obesity
Smoking
A home health nurse is preparing to set up a continuous passive motion machine for a client who
is post-op following a total knee replacement. WOTF actions should the nurse respond to take first?
Align the knee joint with the frame joint of the CPM machine
Inspect the CPM machine and electrical cords for possible damage
Place the CPM machine in extension and pad the surface with sheep skin
Set the degree of flexion and extension on the CPM machine
Inspect the CPM machine and electrical cords for possible damage
A nurse is preparing to administer morphine 30mg to a client who reports pain. Available
morphine is 20mg/mL
1.5mL
A nurse is RT about hand hygiene to a newly licensed nurse. WOTF information should the nurse include in her teaching?
Dry hands starting from forearm to fingers
Use hot water to wash hands
Interlace the fingers while rubbing hands together
Apply friction to hands for 10 seconds
Interlace the fingers while rubbing hands together
A nurse is reinforcing dietary teaching with a client who experienced a myocardial infarction. The nurse should encourage the client to limit WOTF?
Saturated fats
Dietary fiber
Omega-3 Fatty Acids Complex
carbohydrates
Saturated fats
A nurse is RT with the family of a client who is terminally ill about the grief process. WOTF information should the nurse include in the teaching?
Anger towards the health care staff is expected
Anticipatory grieving prolongs the grief process
The grieving process should be complete within a year
The stages of grief occur in sequential order
Anger towards the health care staff is expected
A nurse is collecting data from a client who has diabetic Ketoacidosis. WOTF should the nurse expect?
Fruity breath
A nurse in the long term facility is caring for an older adult client who has a history of hypertension. WOTF findings should the nurse recognize as an indicative sign of a Transient Ischemic Attack?
Epigastric Pain
Seizure activity
Sudden loss of vision in one eye
Pain radiating down the left arm
Sudden loss of vision in one eye
A nurse is planning care for a client who recently attempted suicide. WOTF actions should the nurse plan to take?
Keep the client’s door closed when he is in the room
Limit the client’s personals to room only cologne
Observe the client’s behavior every 2 hours
Ensure the client swallows each dose of medicine
Ensure the client swallows each dose of medicine
A nurse is caring for a client who has upper gastrointestinal bleed. WOTF actions should the nurse take first?
Prepare the client for an upper endoscopy
Obtain a prescription for blood transfusion
Insert an NGT for lavage
Check bowel sounds
Check bowel sounds
A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis.
Nuchal rigidity
A nurse is transcribing a prescription from the provider. The prescription reads Gentamicin 2 gtt OD q4h. WOTF information should the nurse clarify with the provider?
Time
Medication
Route
Dosage
Dosage
A nurse is reinforcing discharge teaching with a client whose post-op and who has a prescription of oxycodone. WOTF information should the nurse include to prevent constipation?
Take a stool softener at bedtime
Reduce daily fiber intake
Limit water to 4 glasses per day
Decrease physical activity
Take a stool softener at bedtime
A nurse is reinforcing teaching with a parent of a child who has a new prescription for ferrous sulfate in liquid form. WOTF statements by the parent indicates an understanding of the teaching?
I will notify the provider if my child becomes nauseated
I will give the iron through a straw
I will notify the provider if my child’s stools are tarry
I will give the iron with milk
I will give the iron through a straw
A nurse is collecting data from a client who has cholecystitis. WOTF findings should the nurse
expect?
Pain radiating to the jaw
Pain in the right upper abdomen
Increased abdominal discomfort prior to meals
Discomfort with urination
Pain in the right upper abdomen
A nurse is caring for a 3 year old child at a well-child visit. The parents report that their son has
been playing with imaginary friends. WOTF responses should the nurse make?
How many hours per day does your child watch TV?
This is a common behavior for children at this age
You should seek family counseling if this behavior continues
Children have imaginary friends to gain attention
This is a common behavior for children at this age
A nurse is assisting with the physical examination on a 7-year-old child. WOTF options should the
nurse take?
Have a parent remove the child’s outer clothing
Perform the most invasive procedures first
Explain the purpose of the equipment used
Explain findings during the examination
Explain the purpose of the equipment used
A nurse is delegating client care assignments. WOTF tasks should the nurse assign to the assistive personnel?
Reinforce teaching on how to use the glucometer for a client who has diabetes
Monitor a client’s sacral pressure ulcer to determine need for dressing
Reposition client who is experiencing increased ICP
Apply an antiembolic stocking for a client who is 2 days post-op
Apply an antiembolic stocking for a client who is 2 days post-op
A nurse is caring for a client who had a femoral popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate the pulses in the affected leg. WOTF actions should the nurse take?
Place the client in high-fowler’s position
Implement passive ROM
Notify the charge nurse about the findings
Apply a warm, moist pad to the extremity
Notify the charge nurse about the findings
A nurse is caring for a client who has multiple sclerosis and has a new prescription for baclofen.
WOTF indicates that the medication is having its desired effect?
Improved alertness
Improved dexterity
Increased appetite
Increased blood pressure
Improved dexterity
A nurse is assisting with the prenatal examination of a client who is at 8 weeks gestation. The
nurse notices a purplish color of the vagina
Chadwick’s sign
A nurse is caring for a client who recently gave birth to her first child. The baby is crying and the client states, “I can’t seem to do anything right, what should I do?” What is the nurse’s best response?
Let me show you how to swaddle and cuddle him, then you try
I’ll take him back to the nursery
If I turn him on his side maybe it’ll go to sleep
Babies need to cry soon after they are born to develop their hormones
Let me show you how to swaddle and cuddle him, then you try
A charge nurse is observing a newly licensed nurse perform suction on a tracheostomy. Which of the following should the charge nurse intervene?
Suctioning for 30 seconds
A nurse is reinforcing teaching to the support person of the client who has early stage labor. Which of the following instructions should the nurse include regarding effleurage?
Help her not to move early
Breathe in deeply at the beginning of contractions.
Gently stroke her abdomen at the start of her contractions
Apply steady pressure with her pubis to her sacral area
Apply steady pressure with her pubis to her sacral area
A nurse is reinforcing discharge teaching to the family of the client who has Alzheimer’s Disease. The client has wandering behaviour and the family is concerned about safety at home. Which of the following instructions should the nurse include?
Replace door knobs with ones containing simple locks
Keep the client’s shoes at the front door
Contact Law enforcements if unable to locate the client
Obtain a medical bed with side rails to use at night.
Replace door knobs with ones containing simple locks
A nurse is reinforcing teaching with a mother who is breastfeeding her 3 week old newborn. Which of the following instructions should the nurse include in the teaching?
Encourage the newborn to take a pacifier
Offer the newborn supplemental formula twice daily
Feed the newborn every 2-3 hours
Feed the newborn for 30 minutes.
Feed the newborn every 2-3 hours
A nurse is collecting data from a child during a well child visit. Which of the following actions should the nurse take when checking the child’s oculomotor function?
Pupils are equal and react to light.
Pupils are equal and react to light.
A nurse is caring for a client who delivered by C-section 1 day ago. The client requests non pharmacological interventions to manage pain when changing position. Which of the following responses should the nurse make?
Use breathing techniques when changing positions
Splint incisions with pillow when changing position
Change positions as little as possible
You can apply counter pressure to your back with each position
Use breathing techniques when changing positions
A nurse is caring for a client who has a new diagnosis of heart failure and has a new prescription
for digoxin. The nurse should monitor which of the following for an adverse effect?
Insomnia
Hyperkalemia
Seizures
Visual Changes
Visual Changes
. A nurse is caring for a client who has anorexia nervosa. At home the client exercises frequently each day. Which of the following interventions should the nurse implement?
Encourage the client to continue on an exercise routine
Monitor the difference in weight before and after exercise
Allow the client to snack throughout the day
Observer during meals.
Observer during meals.
A nurse is reinforcing teaching to a client who is to start taking ferrous sulfate elixir. Which of the following statements shows client understanding of teaching?
I will mix medication with water
I will report tarry stools to my doctor
I can prevent nausea if I take the medication on an empty stomach
I can prevent constipation if I take milk with this medication
I will mix medication with water
A charge nurse at Emergency Department recommends that a client should be discharged in response to mass casualty disaster. Which of the following clients should the nurse recommend?
A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation
A client who has Diabetes and ketonuria
A client who has hypertension and a new onset of slurred speech
A client who has aortic stenosis and 2 kg weight gain
A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation
A nurse is caring for a mother who is breastfeeding her newborn 1 week after delivery. Which of the following types of stools from the newborn should the nurse expect?
Watery
Firm
Seedy
Gelatinous
Seedy
A nurse is reinforcing teaching about foot care of a client who has Diabetes. Which of the following statements indicates an understanding of the teaching?
I should not use moisturizers on my feet
I should wear the same shoes all day
I can remove my own callus with a pumice stone
I should shake out my shoes before I put them on
I should shake out my shoes before I put them on
A charge nurse is discussing about confidentiality of a client; about sharing the client’s medical record. Which of the following people should the nurse identify as an appropriate person to share client’s information with?
Client’s partner
Social Worker
Client’s Employer
Nurse from another unit
Social Worker
A nurse is assisting to monitor a client who has preeclampsia and is receiving an infusion of
Magnesium Sulfate. Which of the following findings should the nurse expect to stop the infusion and report to the charge nurse?
Diaphoresis
Facial Flushing
Urine Output 40 mL/hr Respiratory rate 10/min
Respiratory rate 10/min
A nurse is providing skin care for a 14-year-old adolescent who is in skeletal traction for a fractured femur. Which of the following actions should the nurse take? Select all that apply.
Massage reddened bony prominences
Check skin every 2 hours
Cleanse skin with soap-free
agents
Use a draw sheet to move client
Elevate the HOB to a 90 degree angle
Check skin every 2 hours
Cleanse skin with soap-free
agents
Use a draw sheet to move client
A nurse is caring for a client who has prescription for Warfarin. What laboratory values should the nurse check?
INR
A nurse in a mental health facility is observing two clients playing cards in the day room. One of the clients becomes agitated and throws the cards on the ground. Which of the following actions should the nurse take first?
Encourage client to express their feelings.
Assist the client to resolve the issue
Administer haloperidol
Place the client into a quiet area
Place the client into a quiet area
A nurse is reviewing the medical record for a child who is scheduled for a Varicella Immunization. Which of the following findings should the nurse recognize as a contraindication.
Chemotherapy
A nurse is reinforcing teaching about sterile technique with a newly licensed nurse. The nurse should include in the teaching. Which of the following procedures requires sterile technique?
Suctioning Tracheostomy
A nurse is reinforcing teaching to a client who has Hypertension about dietary measures to
control blood pressure. Which of the following food selection shows an understanding of teaching?
Grilled cheese
Ham sandwich
Baked chicken
Tomato soup
Baked chicken
A nurse is caring for a client following an electroconvulsive therapy. What action should the nurse monitor?
15 minutes disorientation
A nurse is reinforcing teaching with a client who is planning on becoming pregnant about the dietary intake need to reduce the risk of neural tube defect. Which of the following foods is a priority to include in the teaching?
Rice
Cooked Spinach
Orange juice
Eggs
Cooked Spinach
A nurse is caring for a client who has new prescription for ferrous sulfate. Which of the following
findings should the nurse monitor the client?
Orthostatic Hypotension
Gastrointestinal Distress
Decreased Clotting Time
Orange Urine
Gastrointestinal Distress
A nurse is providing care for a client who has cystic fibrosis. Which of the following effects is a
therapeutic effect of administering pancreatic enzymes?
Reduced fat in the stools
Decreased sodium excretions
Improved respiratory function
Improved absorption of vitamin B and C
Improved respiratory function
A nurse is reinforcing discharge teaching with a parent of a newborn. Which of the following
statements indicates an understanding of the teaching?
“I will use hydrogen peroxide on the cord during each diaper change.”
“I will fold the diaper just below my baby’s cord.”
“I will wash the cord with warm soapy water.”
“I will apply petroleum jelly daily to my baby’s cord.”
“I will fold the diaper just below my baby’s cord.”
A nurse is preparing to administer acetaminophen 50 mg PO to an infant. Available is 80 mg/0.8 mL. How many mL should the nurse administer to the infant?
0.5 mL
A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take?
Ensure the weights are hanging freely
A nurse is caring for a client who is receiving continuous bladder irrigation following a
Transurethral resection of the prostate. Which of the following findings should the nurse report immediately to the provider?
The client suddenly develops bladder spasms
The nurse observes continuous bright, red urinary output
The client passes small clots in drainage bag
The nurse notes drainage flow rate has slowed
The nurse observes continuous bright, red urinary output
Anurseiscollectingdatafromanadolescentclientwhoisexperiencingsexualabuse.Whichof
the following shows that the client is using the defense mechanism of suppression?
“My mother is the real reason for it all because she doesn’t live in the real world.”
“Sometimes, I get angry about it.”
“I drink beer as often as I can so I don’t have to think about it.”
“I have to take some of the blame because of the way me and my friends dress.”
“I drink beer as often as I can so I don’t have to think about it.”
A nurse is assisting with discharge planning for a group of clients. Which of the following clients
should the nurse recommend for a home care referral.
Adolescent who has tibial fracture and requires crutches.
Older adult client who has heart failure and lives alone.
Young adult who has a substance abuse disorder
Middle age adult who has a mastectomy and requires radiation
Older adult client who has heart failure and lives alone.
A nurse is caring for a client who is taking multiple medications about the possible interactions. Which of the following members of the interdisciplinary team should the nurse make a referral to?
Advance practice nurse
Psychologist
Social worker
Patient-care technician
Advance practice nurse
A nurse on the postpartum unit is reinforcing teaching with a client whose baby is 1 day old about the development of sensory behavior. Which of the following statements by the client indicates an understanding of teaching?
“My baby can hear my voice when I talk to him.”
“My baby will recognize the odor of my breath within couple of weeks.”
“My baby will gradually feel me touching his skin.”
“My baby’s eye prefer bright light.”
“My baby can hear my voice when I talk to him.”
A nurse is caring for a client who has an indwelling catheter for a urinary drainage. Which of the following actions should the nurse take?
Instruct the client to hold the draining bag at waist height.
Coil the tube on the bed above the drainage bag.
Secure the tubing to the lower abdomen with adhesive tape.
Collect a sterile specimen from the drainage bag.
Coil the tube on the bed above the drainage bag.
A nurse is on a mental health unit is caring for a client who expresses anxiety. The nurse
promises to walk with the client everyday. Which of the following ethical principles is the nurse displaying?
Fidelity
A charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact
isolation. Which of the following actions by the AP should the charge nurse intervene?
Remove gloves last when taking off PPE
A nurse is reinforcing discharge instructions with a client who had a myocardial infarction. Which of the following statements indicates an understanding of the teaching?
“I should refrain from sexual activity until I can walk 1 mile without stopping.”
“I can have 2.5 g of Sodium each day.”
“I can swallow nitroglycerin pill on the first onset of chest pain.”
“I can take a nitroglycerin pill every 5 minutes up to 3 times to relieve chest pain.”
“I can take a nitroglycerin pill every 5 minutes up to 3 times to relieve chest pain.”
A nurse is caring for a client who has an AV Shunt in his right arm. Which of the following actions should the nurse take?
Check bruit over the shunt on a regular basis
Give IV fluids through the AV Shunt.
Obtain Blood Pressure from the right arm.
Avoid Range-Of-Motion on the right arm
Check bruit over the shunt on a regular basis
A nurse is collecting data from a client who is 12 hour post-op following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?
Oral temperature of 99.7F
Apical Pulse 88/min
Respiratory Rate 20/min
Oxygen Saturation of 90%
Oxygen Saturation of 90%
A nurse is collecting data from a client who is in his third trimester pregnancy, having her routine prenatal visit. The client reports she is dizzy,clammy, and becomes pale lying down. Which of the following actions should the nurse instruct the client to take?
Lie on her left side
Take a brisk walk
Check her temperature
Drink a glass of orange juice
Lie on her left side
A nurse is assisting a client move up in bed. Which of the following action should the nurse take?
Place the bed in the lowest position
Stand with feet together
Ask the client to flex her hips and knees
Raise the head of the bed
Raise the head of the bed
A nurse is reinforcing teaching from a client who has a Urinary Tract Infection and a prescription for antibiotic. Which of the following instructions should the nurse include in teaching?
Take the medication until the manifestations subside
Wear nylon undergarments until manifestations are present
Limit alcohol intake to one beverage per day
Empty bladder every 4 hours.
Empty bladder every 4 hours.
A nurse is performing nasopharyngeal suctioning on an adult client. Which of the following techniques should the nurse use?
Wait one minute between suctioning
Perform inter catheterization of 20cm or 8 inches
Apply intermittent suctioning for 30 seconds
Apply suction while inserting the catheter.
Wait one minute between suctioning
A nurse is caring for a client who has a follow up visit for bipolar disorder and a new prescription for Lithium Therapy. Which of the following indicates Lithium Toxicity?
Urinary retention
Dysrhythmias
Excessive salivation
Hypoglycemia
Dysrhythmias
A nurse is reinforcing teaching for a 36 year old client who is 16 weeks gestation and who is
scheduled for amniocentesis. What is the purpose of amniocentesis?
To determine chromosomal abnormalities
A nurse in a long term care facility has just received change of shift. Which of the following clients should the nurse attend to first?
Client who has a spinal cord injury and needs a dressing change
Client who has a temperature of 101.4 and appears confused
Client who is receiving enteral tube feeding and has a blood glucose of 155 mg/dL
Client who had a hip arthroplasty and is requesting pain medication
Client who has a temperature of 101.4 and appears confused
A nurse is collecting data from a parent of a school age child who is allergic to bee venom. What
should the nurse administer?
Epinephrine (muscle relaxant)
A nurse is caring for a client who has increased ICP following a closed head injury. Which of the following actions should the nurse take?
Place the client in lateral Sim’s position
Monitor the client’s temperature every 4 hours
Wake the client every 6-8 hours
Elevate the Head of the Bed 30 degrees
Elevate the Head of the Bed 30 degrees
A nurse is planning a health promotion program for high school students. Which of the following about cigarette smoking would be the most appropriate to get the students to stop smoking?
Smoking can lead to substance use disorders
Smoking is the no. 1 preventable cause of death
Quitting smoking can help save money for other things
Smoking cause unattractive stain on the teeth and hands
Smoking cause unattractive stain on the teeth and hands
A nurse is preparing to administer intermittent enteral feeding to a client who has a small dour NGT. Which of the following actions should the nurse plan to take?
Chill the formula before administration
Hang the feeding 6 inches above the insertion site
Flush the tubing with 5 mL of water
Elevate the Head of Bed 45 degree
Flush the tubing with 5 mL of water
A nurse is caring for a preschool age child who recently experienced the death of a parent. Which of the following should the nurse expect?
Child curious about funeral service
States everyone dies eventually
States death is punishment for bad behavior.
Recognizes the parent will never wake up
States death is punishment for bad behavior.
A nurse manage is taking measures to increase cost effective. In which of the following client situations should the nurse manager intervene?
An AP dons a mask when providing an oral care to a client who has staphylococcal infection
A nurse uses sterile gauze pads to place a dressing on a surgical wound.
A nurse discards a bottle of saline after it has been opened for 24 hours
An AP is wearing clean gloves when feeding a client who has Hepatitis B
A nurse uses sterile gauze pads to place a dressing on a surgical wound.
A nurse is contributing to the plan of care to a client who has delirium. Which of the following
interventions should the nurse recommend?
Provide the client with four food choices at each meal
Vary the client’s activities daily.
Assist the client to the bathroom every 2 hours.
Assist the client to the bathroom every 2 hours.
A home health nurse is reinforcing teaching with a client about safe food handling to prevent food poisoning. Which of the following instructions should the nurse include in the teaching?
Allow leftover food to cool before refrigerating
Defrost frozen foods in the refrigerator
Set refrigerator to 46.4 degrees
Fahrenheit Cook poultry to 140 degrees Fahrenheit
Allow leftover food to cool before refrigerating
A nurse on a hospice unit is caring for a client that has cancer and is in the active phase of dying. Which of the following findings indicates intervention from the nurse?
Oxygen is in use
Assistive Personnel is encouraging intake of fluids
Benzodiazepines are administered every 4 hours
A family member remains at the client’s bedside for 24 hours
Assistive Personnel is encouraging intake of fluids
A nurse is caring for an adolescent who had a child and is requesting the most reliable method of
birth control. Which of the following should the nurse recommend?
Spermicide
Injectable progesterone
Oral contraceptives
Condoms
Injectable progesterone
A client is collecting nutritional data from a group of adult clients. Which of the following clients
should the nurse recommend an interprofessional conference with a dietitian?
Patient with serum albumin of 4.5
Patient with sodium intake of 1200 mg per day
Patient has a total fat intake 25%
BMI of 32
BMI of 32
A nurse is assisting a client to ambulate when the client begins to have a generalized seizure. What action should the nurse take? (I don’t know the answer for this one)
Place on the side
Supply Oxygen
Oral hygiene
Reorient
Place on the side
A nurse is caring for a client who is 34 weeks gestation. Which of the following statements is the nurse priority to report to the provider?
“Palms of my hands are red and blotchy”
“My heart feels like it skips a beat.”
“Acetaminophen is not working on my persistent headaches”
“I have nosebleeds once a week.”
“Acetaminophen is not working on my persistent headaches”
What is the use/effect of protamine?
Decreasing clotting time
What does it mean when a client is pacing back?
Move the client cards
Client is participating to group therapy
Client returns to the room
Walks to the recreation room
Client returns to the room
What is the adverse effect of the postoperative opioid medication?
Urinary retention
Tachycardia
Diaphoresis
Hypotension
Urinary retention
What is the adverse effect of methylphenidate?
Tachycardia
Ringing of the ears
Metallic taste
Decreased appetite
Decreased appetite
What should be done when the nurse sees a mid-abdominal incision?
Reinforce Dressing
Apply pressure for 30 seconds
Cleanse with normal saline
Notify the provider
Reinforce Dressing
What must be done when the nurse is not sure of calculating the medication dosage
correctly?
Call another nurse to verify the calculation
Recalculate the dosage
Document the incident
Administer the medication
Call another nurse to verify the calculation
What is the adverse effect of Enoxaparin?
Epistaxis
Nausea
Muscle weakness
Hyperglycemia
Epistaxis
What progress must be seen in a four year old child?
Eat vegetables
Familiarize with shapes
Speaking using only 20 to 50
words
Thumb sucking
Eat vegetables
What is the adverse effect of furosemide?
Hypotension
Urinary retention
Fatigue
Hypokalemia
Hypokalemia
What safety measures must be implemented for a 12 month old infant?
Lock the doors and cabinets
Turn pot handles inward
Provide finger foods
Provide a non skid soles
Turn pot handles inward
What action must be done when the nurse finds out that there is a gastric residual prior to
providing bolus feeding?
Notify the provider
Withhold the bolus feeding and check again in an hour
Flush the tube with 240 cc of water
Document the incident
Withhold the bolus feeding and check again in an hour
A nurse is caring for a Asian client who is admitted 2 days ago. Which of the following
practices should the nurse must be mindful of?
Avoid eye contact
Bow
Separate the content of each meals in the tray
Raising the voice
Avoid eye contact
When a nurse is caring for a client who has a terminal cancer, this should be followed strictly.
Treatment times
Isolation precautions
Negative pressure airflow
Advance Directives
Advance Directives
Which of the following tasks the nurse can delegate to the Assistive Personnel to perform?
Catheter care
Dressing change
Fingerstick prior to insulin administration
Performing a head-to-toe assessment
Catheter care
A nurse is caring for a client who is terminally ill, sees the patient’s partner crying and
seemed to be upset. What action should the nurse take?
Ignore the patient’s partner
Encourage the partner to express feelings
Lecture the patient
Call the supervisor
Encourage the partner to express feelings
What should be the action taken when a client is suspected with the manifestations of Bulimia
Nervosa?
Observe the condition and manifestations
Reinforce teaching about proper dietary intake
Notify the provider
Send to the emergency department
Observe the condition and manifestations
The nurse from the morning shift is turning over the reports to the afternoon shift. Which of the following clients must be seen first?
A client who is diagnosed of Guillain-Barre syndrome
A client who has current blood pressure of 165/92 mm Hg
A client who has small laceration on the right thigh
A client who has temperature of 38.5 degrees Celsius
A client who is diagnosed of Guillain-Barre syndrome
Withhold doxycycline if the client is manifesting this symptom.
Crackles
Abdominal distention
Wheezing
Bradycardia
Crackles
What intervention must be implemented for a client who has kidney failure with peripheral
edema?
Decrease water intake
Infuse IV normal saline 0.9%
Ambulate the client to the hallway
Apply antiembolic stockings
Decrease water intake
4 months infant?
Cool mist vaporizer
The LPN/LVN cares for the client after a plaster cast has been applied to the left leg due to a fractured femur. The LPN/ LVN should take which action?
Turn the client every 2 hours
The client has attempted to manage 6 month history of severe joint pain in both knees and
hip joints with over-the-counter-medications. The client states these have not completely resolved the pain. The HCP orders Diclofenac Sodium. When reinforcing teaching about this medication, it is important that the client understands which concern?
Do not take with Aspirin
The family relates having difficulty coping with the emotional outbursts of the family member diagnosed with Alzheimer’s disease. The family members ask the LPN/LVN what they can do about the outbursts. Which response, if made by the LPN/LVN is the best?
Provide a calm, non-chaotic environment
The nursing assistive personnel approaches the LPN/LVN and says, “You need to help my client with morning care because I am not going to be able to get it done.” The LPN/LVN identifies this is an example of which type of delegation?
Reverse delegation
The client diagnosed with colitis, type 1 diabetes, and cholelithiasis describes experiencing pain when chewing and relates the food doesn’t have any flavor. Which response is most appropriate by the LPN/LVN?
“It is normal as a person ages to have osteoarthritis in the jaw and the loss of taste
buds.”
Which statement by the LPN/LVN to the client who is receiving dextroamphetamine (Dexedrine) for daytime sleepiness and fatigue, is the most important?
“Call the healthcare provider’s office immediately if your heart seems to be
skipping beats.”
The LPN/LVN identifies the nursing assistive personnel is using appropriate body mechanics if which finding is observed?
The AP keeps the head erect when lifting a heavy object.
The client has a nasogastric (NG) and T-tube is placed following an open (classic) cholecystectomy. The LPN/LVN understands the purpose of the T-tube is which statement>
To ensure patency of the common bile duct.
The LPN/LVN determines teaching is effective if the client makes which statement about the proper use of nitroglycerin sublingual tablets?
“I should take 1 nitroglycerin tablet and repeat the dose in 5 minutes if the chest pain is unrelieved.”
The client with chronic bronchitis says to the LPN/LVN “I do okay until my wife starts smoking, then my bronchitis gets bad again.” Which statement by the LPN/LVN would be most appropriate?
“It is very important for your medical condition that your wife not smoke.”
The client is in active labor and says, “Help me! I have to push! I have to push now!” Which is the best response?
“Take a deep breath and bear down like you are having a bowel movement.”
The LPN/LVN obtains vital signs from the client: oral temperature of 97.6F (36.4C), radial
pulse of 80 bpm, Respiration rate is 28, and B/P 110/60. Which action should the LPN/LVN take next?
Report the vital signs to the registered nurse in charge.
- The client diagnosed with cancer of the pancreas reports mild to moderate pain within the past week. Based on this, the LPN/LVN should recommend which to the client?
Continue with non-opioid analgesics as your were doing.
The LPN/LVN cares for the 4 year old child with cast on his left arm due to a fractured wrist. The child states “The cast feels funny over my wrist bone”. Which is the best response from the LPN/LVN?
“I will talk with the health care provider.”
The nurse cares for the client who just underwent through an abdominal surgery. To increase the client’s comfort level, it is most important for the nurse to place the client in which position?
Sitting upright in a chair.
Prone with knees straight
Left side-lying
Supine with knees flexed
Prone trendelenburg lithotomy
Which explanation about a thoracentesis by the nurse would be most appropriate?
“The HCP will be removing fluid from your pleural space.”
The client who is having frequent diarrhea is diagnosed with methicillin-resistant
staphylococcus aureus (MRSA) and is placed on contact precautions. The nurse should intervene if the nurse observes the AP performing which action?
The AP takes the blood pressure cuff out of the client’s room
The nurse finds the client unresponsive on the floor, what should the nurse take first?
Check respirations and pulse
The nurse knows that a modifiable risk factor related to reducing the possibility of a second
myocardial infarction would be which factor?
Change of diet to reduce fat intake
The nurse cares for the client who returned from a traditional cholecystectomy 45 minutes ago. Since that time, the client’s NG tube has been draining 75-100 mL per hour and the fluid appears to be slightly blood tinged. The nurse must take which action first?
Report the condition to the RN immediately
The nurse begins to prepare the deceased body for viewing by the family due to arrive in 20 minutes. The nurse is paged to assist a client to eat breakfast and to help another with morning care and transfer to the chair. Which action by the nurse is most appropriate?
Delegate the clients requiring help with breakfast and morning care to the nursing
assistive personnel and continue to prepare the body
The nurse observes the client falling out of a chair; which action should the nurse take first?
Stay with the client and ask the AP to get the RN
The nurse should offer the client which food for a clear liquid diet?
1⁄2 cup of strawberry gelatin
The nurse observes an AP place a hot water bottle directly on the skin of an elderly patient. Which of the following action should the nurse take first?
Immediately remove the hot water bottle
The client insist that the nurse remove her vest restraint “immediately”. What action by the nurse is best?
Check the health care provider’s order to determine the criteria for removing the
restraint.
The nurse knows that the treatment for pleurisy is which implementation?
An anti inflammatory medication
The nurse works with the client taking phenytoin for seizure prevention. Which instruction is
the most essential for the nurse to reinforce regarding this medication?
Notify the health care provider immediately if a skin rash develops
The RN mentions that the client diagnosed with borderline personality disorder uses the defense mechanism of splitting. The nurse recognizes which presentation exemplifies splitting?
Views other as either all good or all bad
The elderly client is admitted with severe substernal chest pain, tachypnea and tachycardia. The client’s skin is cool and clammy. The client becomes listless and has decrease in level of consciousness. The nurse correctly identifies the cause of the client’s symptoms as which process?
Cardiogenic shock
The nurse cares for the client diagnosed with a tension pneumothorax. The client asks the nurse, “which is the most serious complication?”.
Mediastinal shift
The nurse identifies which position is the best for the client immediately post liver biopsy?
Right side-lying
Right side-lying
Following a tornado, the nurse assists a disaster team by gathering data for victims who are
not physically injured. Which interview question is the best?
Please share with me what help you need at this time.
The client diagnosed with asthma currently takes beclomethasone dipropionate. The nurse is aware that the most serious side effect of this medication are which findings?
Bronchospasm and angioedema
The nurse cares for an elderly client diagnosed with type 2 DM and partial-thickness burns of unknown origin on the lower legs and feet. Which reason if stated by the nurse is most likely cause of the burns?
Diabetes not being managed appropriately
The client reports a sad mood, loss of pleasure in usually pleasurable things, and an inability to sleep through the night. No manic episodes or psychotic behavior is noted in the outpatient clinic. The nurse correctly understands that which diagnosis matches this client’s presentation?
Major depression
For three weeks, the client with a spinal cord injury at C7 and has had intensive sessions with PT TID. the nurse determines the client is making expected progress if which finding is observed?
The client is able to independently complete ADL
The HCP orders alprazolam 0.5 mg tablet PO TID. the available tablet contains 0.25 mg. How many tablets should the nurse give?
6 tabs
The client states “I just haven’t felt the best lately, I don’t know what it is, I am not feeling like my usual self.” Based on the client’s hx of two previous MI and HF, which question should the nurse ask?
Have you had any swelling in your feet or lower legs?
The middle aged adult reports fatigue, insomnia, and difficulty focusing on tasks. The client has three teenagers in the home and is the primary caregiver for the client’s elderly mother with significant health problems. The nurse knows that one of the difficulties in this situation is what?
Being a member of sandwich generation
The 3 month old infant was brought to the emergency room with a dx of SIDS. which question is the most appropriate for the nurse to ask?
What did the baby look like when you found him/her
The nurse suctions the client’s trache, what is the most important action?
Apply suction no longer than 10 seconds
The nurse instructs the AP to complete a bath for the client. The AP claims that they do not
have enough time. What action should the nurse take?
Report to supervisor
Which instruction is essential for the nurse to give the client who has venous thromboembolism of the left leg?
Bed rest must be maintained until the anticoagulant therapy is begun
Client has COPD and pulmonary edema. Action
Raise the head of the bed
Living Will
- Client’s wishes regarding medical treatment in the event the client becomes incapacitated and is
facing end-of-life issues. - Example: CPR, Mechanical ventilation, feeding by artificial means.
- HCP who follow the health care directive in a living will are protected from liability.
Durable Power of Attorney
- Designates an individual authorized to make health care decisions for a client who is unable.
- Proxy must be very familiar with the client’s wishes.
- DNR or AND is written: nurse should initiate CPR when a client has no pulse or respirations.
- Provider consults the client and the family prior administering a DNR or AND.
Client’s decisions are priority.
Requesting Reassignment of a Client
- Negotiate with the charge nurse
- No resolution: concern up the chain of command
- Failure to accept the assignment without following the proper channels may be considered
abandonment.
Plan of Care for a client who has bulimia nervosa
- Therapeutic communication
- Encourage client in decision making
- Promote cognitive reframing, relaxation techniques, journal writing, desensitization exercises
- Support groups
- Work with the dietitian
- Small frequent meals
- Diet high in fiber
- Diet low in sodium
- Limit high-fat and gassy foods
- Multivitamin and mineral supplement
- Avoid caffeine
- Meds: SSRI (fluoxetine [Prozac])
Schedule a dental exam ←- this is the answer
Monitoring the performance of Assistive Personnel
- Right task, circumstance, person, communication/direction, supervision/evaluation
Tasks that can be delegated to APs:
➔ ADLs
➔ Feeding without swallowing precautions
➔ Specimen collection
➔ I and O
➔ V/S for stable clients
Task that cannot be delegated to APs:
➔ TEA: teaching, evaluation, Assessment
Client safety versus breach of Confidentiality
- Right to privacy
- Information about the client, verbal and in writing, must be shared only with those who are
responsible for implementing the client’s treatment plan. - Others who are not involved need the client’s consent.
- Patient in mental hospital have the right to refuse meds and make decision, even if admitted
against will. There has to be a court order to say other wise.
Guidelines for Documenting Client Care
- Factual
- Accurate and concise
- Complete and current
- Organized
- Show trends in v/s, b/g levels, pain levels, and others
- Narrative documents = storylike manner
- Subjective-Objective-Assessment-Plan
- Problem-Intervention-Evaluation
- Data-Action-Response
Care following a tracheostomy
- Keep the following at the bedside: two extra tracheostomy tubes (one same size and one
smaller), o2 source, suction catheters and source, and BVM - Provide methods to communicate with staff (pen, paper, dry-erase board)
- Adequate humidification and hydration
- Oral care q2h
- Trache care q8h
- Suction/yankauer
- Remove soiled dressings and excess secretions
- O2 source loosely - if O2 sat decreases
- Remove and clean the inner cannula
- Clean the stoma site and trache plate
- Place fresh dressing under and around the tracheostomy holder and plate
- Replace ties if they are wet or soiled.
- Two fingers fit between the tie and neck
- Replace non disposable trach tubes per 6 to 8 weeks
- Do not shake bedding
- Position the client upright and tip his chin to his chest during meal time.
Reinforcing teaching about Ostomy Care
- Hand hygiene
- Stoma: moist, shiny, and pink; peristomal area must be intact
- Use mild soap and water to cleanse the skin, gently dry
a. No moisturizing soaps - Apply paste/ skin barrier and pouch
- Measure and draw where to cut the skin barrier, allowing only the stoma to appear through the
opening.
Obtaining a Telephone Prescription from a provider
- Have a second nurse listen to a telephone prescription
- Repeat the order back, making sure to include the medication’s name, dosage, time, and route.
- Question any prescription that may seem inappropriate for the client.
- Make sure the provider signs the prescription in person within the time frame the facility specifies,
typically 24 hr.
Evidence-Based Practice
- Always check the information from the Patient’s Chart.
Client Advocacy
- A person who publicly supports or recommends the client’s rights.
Managing Client care: responding to an assistive personnel who refuses an assigned task
- Discuss with the AP upon the behavior
- Report to the charge nurse
Postoperative Care: Prioritizing client care
- Priorities:
- Bleeding
- Report to the provider STAT
- Airway and breathing
- Monitor o2 sat
- Assist with coughing and deep breathing at least every 2 hr
- Provide pillows or folded blanket
- Use of Incentive spirometer at least every 2 hour
- Repositioning
- Circulation
- Do not put pillows under knees or elevate the knee gatch on the bed
- Encourage early ambulation
- Fluid status
- Push IV solution of dextrose 5% in 0.45% NaCl
- Ice chips and fluids as prescribed/tolerated
- Frequent oral hygiene
- Pain
- Monitor clients who receive pain medications via PCA pump
- Assess pain level frequently
- Observe manifestations (increased pulse, respirations, b/p, restlessness,
moaning during movement) - Monitor adverse effects of opioids (respiratory depression, nausea, urinary
retention, and rconstipation) - Provide analgesia 30 minutes before ambulation or other painful procedures
- Kidney function
- Monitor and report urinary outputs of less than 30 ml/hr
- Palpate bladder
- Use bladder scan if necessary
- SeeDuring a bladder scan, pt should not feel any discomfort
- Bowel function
- Maintain NPO until gag reflex and peristalsis returns
- Irrigate NG suction tubes with saline
- Do not move the NG tubes in clients who are postoperative gastric
surgery as order by surgeon - Monitor bowel sounds
- Advance diet as prescribed and tolerated (clear liquids to regular)
Guidelines for documenting client care
- Trends in v/s, blood glucose levels, pain level, and other frequent assessments
- Narrative with sequence of events
Delegating tasks to an assistive personnel
- AP’s do not drink TEA (T-Teach, E-Evaluate, A-Assess)
- Everything that does not involve any medical
- ADLs
Conflict negotiation
- Avoiding/withdrawing
- Both parties know there is a conflict; refuse to face it or work
- Smoothing
- One party attempts to “smooth” another party; trying to satisfy the other
- Competing/coercing
- One party pursues a desired solution
- Party who loses may experience anger
- Cooperating/accommodating
- One party sacrifices something, allowing the other party to get what it wants
- Original problem may not actually be resolved
- Compromising/negotiating
- Each party gives up something
Vital signs: Evaluating assistive personnel measuring tympanic temperature
- Pull the ear up and back (ADULT); down and back (CHILD YOUNGER THAN 3)
- Place the thermometer probe snugly into the client’s outer ear canal and press the scan button.
- Leave it in place until you hear the signal
- Carefully remove the thermometer from the ear canal and read the temperature
- Earwax can alter the reading
- Room temperature can also alter readings
Ethical principle of Autonomy
- Client has the right to make his/her own decisions.
Maintaining Client’s Safety
- Client has orthostatic hypotension:
- Instruct the client to avoid getting up too quickly, sit on the side of the bed for 30-60
seconds prior to standing, and stand at the side of the bed for a few seconds prior to
walking. - Ensure that the client knows how to use the call light and it is within reach
- Responds to call lights asap
- Orient the client
- Place them near the nursing station
- Bedside tables are within reach
- Bed in low position
- Keep bed rails up
- Avoid full side bed rails
- Nonskid footwear
- Keep the floor free from clutter
- Keep assistive device nearby
- Lock wheels on beds, w/c, and carts
- Use chair or bed sensors to alert staff
Emergency management of an evisceration
- Risk for deep-vein thrombosis
- Prophylactic measures: administration of lower-molecular-weight or low-dose heparin or
low-dose warfarin (Coumadin), anti embolism stockings, pneumatic compression devices,
range of motion exercises, and early ambulation - Avoid any form of pressure behind the knee with a pillow or blanket, which can cause
constriction of blood vessels and decreased venous return - Avoid dangling client for long periods of time
- Provide adequate hydration by administering IV fluids or encouraging increased oral fluid
intake
Providing cost-effective care
- Using all levels of personnel to their fullest when making assignments
- Providing necessary equipment and properly changing clients
- Returning uncontaminated, unused equipment to the appropriate department for credit
- Using equipment properly to prevent wastage
- Providing training to staff unfamiliar with equipment
- Returning equipment (IV, kangaroo pumps) to the proper department as soon as it is no longer
needed
Reporting client care issues to an interprofessional team
- Place the client in private room with private bathroom
- Delegation and Supervision: Tasks for an assistive personnel
- Increased intracranial pressure disorders: Prioritizing client care
- Airway management: required equipment for home suctioning-yanker
2) Safe and Infection Control
Alzheimer’s Disease: Maintaining a Safe Environment
- check the Pt’s skin weekly for breakdown
- put a bed alarm or mat sensor alarm
- Remove clutters
- Cables along the wall
Hygiene: Assisting with a tub bath
- Gather all necessary supplies
- place a rubber mat on the tub floor
- assist the patient into the bathroom
- Instruct the patient on using safety bars when getting in and out of the tub
- Instruct the patient to remain in the tub for no longer than 20 min
Neurocognitive Disorders: Planning Care in an Adult Day Care Setting
- Check Mental Status
- Introduce age-appropriate activities
Safe Medication Administration and Error Reduction: Clarifying Prescription Information
A. The Patient
1. compare the name on the client’s wristband with the name on the MAR
2. ask the client to state his DOB
3. ask the client to state his name
4. use the bar-code scan to ID the client
B. Prescription
1. Compare prescriptions with MAR
2. Question unclear prescriptions and call the provider for clarifications
3. Repeat back when taking prescriptions by phone
Discharging Clients During a Mass Casualty Incident
- casualties are separated in relation to their potential for survival, and treatment is allocated
accordingly
Maintaining a Safe Environment: Caring for a client who has MRSA
Have specialized equipment for patient. Own room and bathroom
The AP keeps the blood pressure cuff inside the client’s room
Transmission precautions:
Contact precautions for wound, skin, and urine infection; droplet precautions for sputum infection
No treatment needed for patients with colonization only.
Provide emotional support to the patient and family members.
Consider grouping infected patients together and having the same nursing staff care for them.
Use meticulous hand-washing technique.
Use standard precautions and contact precautions, droplet precautions, or both as indicated.
Provide skin and wound care as indicated; inspect wound and skin for changes and evidence of
healing.
Administer antibiotics as ordered; if I.V. route is used, ensure patent I.V. access and provide I.V.
site care according to facility policy.
Obtain cultures of wound as ordered
Home Safety: Home Inspection for a Client Education regarding home oxygen
Teach the patient and family to place an oxygen in use sign on the door at home and to keep
oxygen delivery systems at least 10 feet away from any open flames.
Record the method of oxygen delivery and flow rate.
Document the patient’s response to oxygen therapy.
Record the dates of your patient teaching sessions about safe home oxygen therapy.
Review the medical prescription for delivery method and flow rate.
review the delivery method and flow rate specified on the medical order.
Inspect all electrical equipment in the patient’s room for the presence of safety-check tags.
Client safety: Equipment Malfunction
remove the equipment with frayed cord or missing part
report equipment having malfunction or misuse issues
ensure that equipment is safe and if not working appropriately, have it sent for repair within the
facility
Applying restraints to a client
Applying the restraints after the order is written by the HCP
Client complains of tingling in the fingers on the right hand require immediate attention
tie restraints:
-tie to the bed frame (not side rail)
-never tie a true knot (quick release buckle)
-check for 2 finger looseness
Documentation
-ongoing assessment required
-include behavior that necessitated need, procedure used, condition of body part, client
response
side rails restraint
-most commonly used physical restraint
-clients can become trapped or fall from when trying to exit a bed
-the FDA cautions use
Safety Hazard for a Client who has an Immune Deficiency
- clean up blood spills immediately with chlorine bleach
- Use standard precautions
Interventions for a client who has herpes simplex
- Implement contact precautions
- Discourage the use of Over-the-Counter products
Home inspection for a client
- Too long to type but:
- Prioritize: Airway, fall risk, risk for aspirations, burns, poisoning, injury, drowning
Monitor client for adverse effects of cyclosporine
- primarily occurs in the kidneys, with up to 75% of pts experiencing reduction in urine output
- Over 50% of pts: hypertension and tremor
- Other common: headache, gingival hyperplasia, elevated hepatic enzymes
- Periodic blood counts are necessary to ensure WBC’s don’t fall below 4,000 or platelets below
75,000 - Long-term therapy increases risk of malignancy - especially lymphomas and skin cancers
Health promotion of infants (2 Days to 1 Year): Reinforcing teaching about home safety
- Parents must make sure that there is only one finger between the crib and the railing.
Home safety: Setting up medical equipment
- Oxygen:
- Place no smoking sign
- Smoke outside the house
- Ensure that electrical equipment is in good repair and well grounded
- Keep flammable materials such as heating oil and nail polish remover away from the
client
Tuberculosis: Patient teaching about infection precautions
-Wear a mask or respirator prior to room entry, depending on the disease-specific
recommendations. ( Most disease will require N95 or higher respiratory protection.)
-Place patient in an airborne infection isolation room ( AII)- single room that is equipped with
special air handling and ventilation capacity.
-AAIR room (negative pressure room).
-When transferring the patient, have the patient to wear surgical mask prior to being transferred
Diabetes mellitus management and complications: Evaluating client understanding about foot
care
- Check for bruises or sores
- Always wear socks or slippers as protection
- Use lotion to prevent cracks and skin dryness
- Never cut the toenails
- Podiatrist will do it for elder clients
- Use nail file, not nail cutter
IV Therapy: Patient teaching about a peripherally inserted central catheter line
Neurologic diagnostic procedures: Caring for a client who has a prescription for cerebral
angiogram
Ergonomic principles: Using correct body mechanics to move a client
- The wider the base of support, the more stable the object, within limits. (The feet must
not be too wide apart, as this would cause instability.) The feet are spread sidewise when
lifting, to give side-to-side stability. - Get the patient close to your body when moving
- The AP keeps the head erect when lifting a heavy object.
Arthroplasty: Caring for a client using a continuous passive motion device
Cancer treatment options: Caring for a client who is immunocompromised
3) Health Promotion and Maintenance
- Complications of the Newborn: Findings to report to the provider during phototherapy
a. Notify provider if jaundice is worsen
- Phototherapy nursing care:
a. Maintain an eye mask over the newborn’s eyes for protection of corneas and retinas
b. Keep the newborn undressed with the exception of male newborn. A surgical mask
should be placed like a bikini over the genitalia to prevent possible damage to the
testicles during the therapy. Be sure to remove the metal strip from the mask to prevent
burning
c. Avoid applying lotions or ointments to the skin because they can cause burns
d. Remove the newborn from the light ever 4 hours and unmask the newborn’s eyes. Check
the eyes for damages or injury
e. Reposition the newborn every 2 hours to expose all of the body
f. Turn off the lights before drawing blood
g. Bronze, maculopapupular skin rash are not serious complications
h. Monitor elimination and daily weight. Encourage breastfeeding to help with excretion of
bilirubin in the stools
i. Maintain adequate fluid intake to prevent dehydration
Newborn data collection: Findings to report
a. Jaundice
b. Low heart rate
Responding to the caregiver of a client who has Alzheimer’s Disease
a. Provide verbal and nonverbal ways to communicate with the client
b. Reminisce
c. Stimulate the memory by repeating the client’s statement
d. Orient to reality
e. Do not argue
f. Speak directly with concise sentences
g. Use calm tone
Reinforcing teaching about breastfeeding
a. Allow 20-30 mins for each breast to be completely emptied
b. If the baby is falling asleep, the baby is full. Do not force feed because it could lead to
overweight
Hospitalization, Illness, and Play: Developmentally appropriate activities for an adolescent
a. Nonviolent video games
b. Nonviolent music
c. Sports
d. Caring for a pet
e. Career training programs
f. Reading
g. Social events (going to movies, school dances)
Immunization: Contraindication to receiving varicella immunization
a. If the client is allergic to gelatin
b. Immunosuppressed patients
c. Is or may be pregnant
d. Received blood products (whole blood, plasma, etc) during the previous 3-1 months
Contraception: Appropriate use of contraception
a. Ensure that the rim is outside so it looks like a little hat. If you accidentally put it inside
out, get a new one. DO NOT flip it.
b. Pinch the tip of the condom and place it on the head, leaving a little space at the top
c. Roll to the shaft
d. Have fun
e. Take it off after the party
Hypertension: Low-Sodium food recommendations
a. Fish or shellfish
b. Chicken or turkey breast without skin
c. Lean cuts of beef or pork
d. AVOID:
i. Salty snack food
ii. Canned soups and vegetables
iii. Baked goods that contains baking powder or baking soda
iv. Processed meat (bologna, ham, bacon)
v. Dairy products, especially cheese
vi. Pickles
vii. Olives
viii. Soy sauce, steak sauce
ix. Salad dressings
Preparing a client for a colposcopy
a. Avoid scheduling it during your period
b. No vaginal intercourse the day or two before your colposcopy
c. Don’t use vaginal medications for the two days before
d. Take OTC pain reliever before going to the appointment
Sources of nutrition: Increasing fiber intake
a. Foods high in fiber:
i. Raspberries, strawberries
ii. Pear and apple with skin
iii. Orange
iv. Whole wheat
v. Brown rice, rye, bread
Thorax, heart, and abdomen: Identifying understanding of health promotion
?
Older Adults (65 and +): Health promotion behaviors
a. Recommend herpes zoster immunization
b. Exercise
c. Social interactions
Expected findings with an acetaminophen overdose
- Diarrhea
- Change in renal hormones (ALT/AST > 1000 uL/d)
- Monitor change in BUN/Creatinine level
Depressive Disorders: Priority finding to report
a. depressed mood
b. difficulty sleeping or excessive sleeping
c. Indecisiveness
d. -decreased ability to concentrate
e. -suicidal ideation
f. -increase or decrease in motor activity
g. -inability to feel pleasure (anhedonia)
h. -increase or decrease in weight of more than 5% of total body weight over 1 month
Psychotic Disorders: Identifying negative symptoms of schizophrenia
a. Apathy
b. Affect -: blunted or flat expressions
c. Alogia-: poverty of thought or speech
d. Anergia-: lack of energy
e. Anhedonia-: lack of pleasure or joy
f. Avolition-: lack of motivation
Characteristics of perpetrators of child abuse
a. age
b. gender
c. step parent
d. single parent
e. psychological characteristics
Reinforcing teaching about oppositional defiant disorder
a. Assessment-: Hx, environmental, symptoms
b. Provide psychoeducation to orient parents
c. Establish nurturing and positive parent-child interactions
d. Increase authoritative parenting and child compliance
e. Improve parental use of personal anger management and problem solving skills
Reinforcing rules with a client who has antisocial personality disorder
a. Use therapeutic communication (don’t yell)
b. Calm the patient and prevent self harm and to others.
Anger management: Responding to escalating aggression
a. Respond quickly
b. Remain calm an in control
c. Encourage client to express feelings verbally (use therapeutic communication)
d. Allow the client as much as personal space as possible
e. Maintain eye contact by sitting or facing the client
f. Communicate with honesty, sincerity, and non aggressively
g. Avoid accusatory or threatening statement
h. Reassure the client staff member are present to prevent loss of control
Appropriate Therapeutic Response
a. Use calm tone
b. Never ask why
c. Encourage to open up feelings
d. Never give false assurance
Identifying culture-bound syndromes
a. These are mental disorders that affect a single cultural group, therefore, are often unknown
outside their own regions.
Kosher Diet
a. Milk(Dairy) and meat cannot be served on a same meal tray.
b. Pig and camel are avoided
Multiple Sclerosis: Priority Action for a client who has Multiple Sclerosis
a. Prevent injury. (No Tx but aimed at relieving symptoms)
b. Pt. should avoid stressors that exacerbate the condition. During exacerbation, administer
corticosteroids.
c. Teach self-catheterization if needed
Benign Prostatic Hyperplasia: Postoperative care following transurethral
- During this immediate postoperative period your doctors will monitor closely for post-TURP
syndrome, a rare but serious condition that occurs when too much fluid is absorbed during the
TURP procedure. The initial symptoms include dizziness, headache, and a slow heartbeat, and it
can progress to shortness of breath, seizures, and even coma. - A catheter placed through your penis into your bladder will remove urine until your prostate heals.
The catheter will stay in place for a few days after surgery. If you go home with your catheter, the
nurse will show you how to clean around it with soap and water. Cleaning your catheter twice a
day will prevent infection.
Planning postoperative care for above the knee amputation
- Encourage to use overhead trapeze
- Give medication for phantom pain
- Monitor cap refill by comparing extremities
- Observe for edema, necrosis, and lack of hair distribution of the extremity due to inadequate
peripheral circulation - Prevent postoperative complications (hypovolemia, pain, infection)
- Assess surgical site for bleeding. MOnitor VS frequently
- Monitor tissue perfusion of end of residual limb
- Monitor and treat pain
- Monitor for signs of infection and/or non healing of incision. Infection can lead to osteomyelitis.
- Client’s perception and feelings regarding amputation of body part.
- Residual limb preparation and prosthesis fitting.
- Client Education
Atopic Dermatitis; manifestations, treatment, and interventions
- Type of eczema that is characterized by pruritus (itching) and associated
- With a history of allergies that are of an inherited tendency (atopy)
- Lesions disappear if the scratching is stopped
- Cannot be cured but can be well controlled
- Antihistamines - Hydroxyzine (Atarax) or diphenhydramine (Benadryl)- teach about sedating
effect, safety measures - Antihistamines - Loratadine (Claritin) or fexofenadine (Allegra), oral for antipruritic effect,
preferred for use during the day time - Antibiotics should be used to treat secondary infections
- Topical corticosteroids- to reduce or control flare ups
- NSAIDs- decrease inflammation during flare ups- older than 2 years old, at start of exacerbation
- Keep skin hydrated with tepid baths (with/without mild soap or emulsifying oil), then apply
- an emollient within 3 min of bathing. -Two or three baths may be given daily with one prior to
bedtime. - Dress the child in cotton clothing.
- Avoid wool and synthetic fabrics.
- Avoid excessive heat and perspiration, which increases itching.
- Avoid irritants (bubble baths, soaps, perfumes, fabric softeners).
- Provide support to the child and family.
- Wash skin folds and genital area frequently with water
Reinforcing teaching about range-of-motion exercises
- Range-of-motion exercises help patients who are unable to ambulate or exercise maintain joint
mobility and muscle strength. They are usually performed once or twice daily, or according to the
provider’s order and can be performed independently or with assistance. - Active range-of-motion exercises are those the patient performs, with a nurse or a physical
therapist supervising to ensure that the patient is doing them correctly. They involve moving each
joint through its complete range of motion. These exercises maintain and increase muscle
strength and help keep joint problems and contractures from developing. - Passive range-of-motion exercises are performed for patients by a nurse or a physical therapist.
They also involve moving each joint through its complete range of motion. These exercises are
performed so that patients who are completely immobilized can retain as much joint range of
motion as possible. Because muscles do not contract during passive range-of-motion exercises,
muscle strength is neither maintained nor increased.
Interventions following knee arthroplasty
- Pulses and circulation checks should be done every one (1) to two (2) hours postoperatively.
- Weight-bearing limits on the affected Knee with an immobilizer on the affected joint to provide
stability. - Continuous Passive Motion (CPM) is used only while the patient is in bed and ordered with
support from Physical Therapy. Sheepskin is used to prevent injury on skin. - Rationale for continuous passive motion (CPM) machine and frequency of use 8-12 hours/day.
- Cryopak therapy or Ice packs to reduce swelling and inflammation.
- 1st Line intervention is Ice Not directly on joints
- Encourage to use overhead trapeze <~ this is the answer
Stroke: assisting a client with meals
- Elevate the head of bed 45 to 90 degrees
- Add thickener
- Place food on non affected side of the mouth
- AP can help them feed
Patient teaching about music therapy
- Music therapy can help her verbally express emotions
- Music therapy works as a distraction and can help alleviate her pain
- Music therapy can help facilitate mvmt in some clients who have mobility limitations
Osteoarthritis and Low-Back Pain: Teaching about exercise
- Water aerobics, water exercises
Mobility and Immobility: Using an Aquathermia Pad
A waterproof plastic or rubber pad that can be applied to areas of muscle sprain, edema, or mild
inflammation. The pad contains channels through which heated or cooled water flows.
Electrolyte imbalances: Teaching with a client who is taking a diuretic
- Check potassium levels
a. Norms: 3.5-4.5 - Check for dehydration s/s :Tachycardia, weak, thready pulse, Hypotension, orthostatic
hypotension, decrease central venous pressure,Tachypneic (increased respirations), hypoxia,
Hyperthermia, diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs,
flattened neck veins, poor skin turgor, tenting, dizziness, syncope confusion, weakness, fatigue,
GI: Dietary teaching about celiac disease
- For this disease, eliminate gluten from diet, give vitamin (ADEK - fat soluble) supplements. Can
have rice & corn.
Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease: Interventions for
CKD
- Control protein intake based on the client’s stage of chronic kidney disease and type of dialysis
prescribed. - Restrict the client’s dietary sodium, potassium, phosphorus, and magnesium.
- Provide the client a diet that is high in carbohydrates and moderate in fat.
- Restrict the client’s intake of fluids (based on urinary output).
- Monitor for weight gain trends.
- Adhere to meticulous cleaning of areas on skin not intact and access sites to control infections.
- Balance the client’s activity and rest.
Math: IV Infusion rate
- [Volume (mL)/ time (min)] X drop factor (gtt/mL)
Priority action when mixing insulin
- Draw regular insulin first (Lispro, Aspart) before NPH insulin
- Cannot mix glargine with anything
DM Patients: Reinforce teaching about insulin lispro and insulin glargine self-administration
- HAND HYGIENE FIRST
- Make sure the insulin is at room temperature before administration
- Most common injection sites: abdomen (two inches away from the umbilicus)
- Insulin pen: make sure to change cartridges before administration
- Make sure to discard needles where it’s away from harming self and others
Safe medication administration and error reduction: Identifying a client prior to medication
administration
- Check patient name, order and medication THREE times prior to giving the medication
Complications of postpartum period: Administration of medications for hemorrhage
- Uterine atony is the most common cause of hemorrhage
- Medication:
- Oxytocin (can be on continuous IV or 10 units IM)
- Methylergonovine (avoid for people with HTN, preeclampsia or any cardiovascular
disease) - Prostaglandin F2 Alpha (avoid for people with asthma; caution for people with HTN,
Cardiac disease) - Misoprostol (taken PO or SL)
Nonopioid analgesics: Contraindications for acetaminophen
- Liver failure, renal impairment, inflammation of liver due to Hep C
Recommendations for Managing Iron-Deficiency Anemia
- Oral iron therapy
- Do NOT administer parenteral iron therapy for those doing oral therapy (will cause
anaphylaxis) - Blood transfusion
Monitoring for Adverse Effects of Enoxaparin
- Epistaxis
Monitoring for Adverse effects of High-Ceiling Diuretics
- hypokalemia, hypomagnesemia, alkalosis, hyperglycemia (C/I in DM), hyperuricemia (C/I in gout)
and dyslipidemia (seen with thiazides). Thiazides cause hypercalcemia while loop diuretics
causes hypocalcemia
Calculating an Enoxaparin Dosage
- Answer: 0.99 (ROUND IT OFF TO 1)
Nursing care of newborns: Phytonadione Injection
- Use to treat or prevent low levels of blood clotting factors that the body normally produces
- Help thicken blood
- Normally given within 1 hour after birth
- Dosage: 0.5-1 mg IM
Priority findings to report for Penicillin G Potassium
- nausea
- vomiting
- pain, swelling, or redness in the area where the medication was injected
- rash
- hives
- itching
- difficulty breathing or swallowing
- swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs
- hoarseness
- fever
- muscle or joint pain
- stomach pain
- severe diarrhea (watery or bloody stools) with or without fever and stomach cramps that may
occur up to 2 months or more after your treatment - unusual bleeding or bruising
- blood in the urine
- seizures
- weakness
- fast, slow, or irregular heartbeat
- return of fever, sore throat, chills, or other signs of infection
Client teaching about a loop diuretics
- Use to treat HTN and edema due to renal insufficiency and congestive heart failure
- Makes the kidney pass more fluids
- Side effects: hypokalemia, hyponatremia, headache, thirst, muscle cramps, hyperglycemia
- Examples: furosemide (lasix), Bumetanide,
Indications of Fluid Overload
- Overhydration:
- Strenuous exercise with fluid replacement but not replacement of electrolytes.
- Subjective and objective data for fluid excess
- Subjective and Objective patient Data
- Vital signs: Tachycardia, bounding pulse, hypertension, tachypnea, increased
central venous pressure - Neuromusculoskeletal: confusion, muscle weakness, headache
- Gastrointestinal : weight gain and ascites
- Respiratory: Dyspnea, orthopnea, crackles, diminished breath sounds
- Other signs: edema, distended neck veins, pale and cool skin
- Labs/tests:
- Decreased osmolarity ( hemodilution) of less than 270 mOsm/L
- Electrolytes, BUN and creatinine are decreased
- Respiratory alkalosis ( When too much PaCO2 is being released, due to tachypnea)
PACO2 is less than 35 mmHG, in which increases PH to greater than 7.45 (alkalosis)
because the ratio of bicarbonate is too high (it’s the carriers of CO2 out of the blood).
Reinforcing teaching about nystatin suspension
- Use a dose-measuring cup, spoon, or dropper to measure the specified dose of thesuspension.
- Swish the suspension around in your mouth, then either spit it out or swallow it, depending upon
the instructions given by your doctor. - Take all of the nystatin that has been prescribed for you even if you begin to feel better
DM: evaluating client use of an insulin pen
- Prefilled cartridges of 150 to 300 units of insulin in a programmable device with disposable
needles. - Used if only one insulin is given at a time
- Convenient for travel
Immunizations: Administration of Herpes Zoster Vaccine
- Recommended for those 60 years old and older
- Contraindications:
- Allergy to gelatin
- Weakened immune system:
- HIV/AIDS
- Cancer treatment such as chemo or radiation
- Cancer affecting bone marrow or lymphatic system (leukemia and lymphoma)
- Who MIGHT be pregnant
Lupus Erythematous, Gout, and fibromyalgia: Patient teaching about skin care
- Use sunscreen
- Use mild protein shampoo, and avoid harsh hair treatments
- Use steroid creams for skin rash
Patient teaching about an amniocentesis
a. It is performed to detect neural tube defect and fetal lung maturity.
b. Report fever, chills, leakage of fluid or bleeding from insertion site, decreased fetal movement,
vaginal bleeding or uterine contraction after the procedure.
c. Drink plenty of liquids and rest for 24 hrs postprocedure.
d. Empty the bladder before the procedure to reduce risk of inadvertent puncture.
Creatinine clearance test
a. Normal creatinine clearance
Men -: 97 – 137 mL/min
Women-: 88 – 128 mL/min
Evaluating treatment for Anorexia Nervosa
- Consider client’s preferences
- Plan an inflexible eating schedule
- Provide small, frequent meals
- Provide a diet high in fiber
- Provide a diet low in sodium
- Himit high-fat and gassy foods
- Administer a multivitamin
- Avoid caffeine
Increased ICP: Manifestations
a. Change in LOC (Headache, restlessness, irritability)
b. Cranial nerve function (eye-blink response, gag reflex, tongue and shoulder movement)
c. Pupillary response (PERRLA, pinpoint or dilated)
d. Amnesia
e. Decrease in motor response (decerebrate, decorticate and flaccidity)
f. Change in Vital Signs (Increasing systolic pressure, Bradycardia, bounding pulse, Irregular
respirations)
g. Seizures
Integumentary and Peripheral Vascular Systems: Locating the Dorsalis Pedis Pulse
- By the inner ankle
V/S: Monitoring Respiration
- Regular rate: 12-20/min
- Regular O2 sat: 90-100%
- Administer O2 therapy if levels are low.
- Raise the head of the bed.
Specimen collection for glucose monitoring: Collecting a postprandial blood sample
- Normal level: 70 to 115 mg/dL
- Taken after meals
DM: Monitoring Laboratory Values
- Fasting blood glucose:
- 126 mg/dL or above
- NPO 8 hrs prior
- No antidiabetic med until the level is drawn
- Oral glucose tolerance test:
- 200 mg/dL and above
- Obtained every 30 minutes for 2 hours
- Consume balanced diet for 3 days prior to the test
- HbAd1c:
- 4 - 6% is normal range
- Best indicator of the average blood glucose level for the past 120 days
- Casual blood glucose concentration
- 200 mg/dL
Respiratory Diagnostic and Therapeutic Procedures: Respiratory Acidosis
- Provide oxygen therapy
- Maintain patent airway
- Low pH; High PaCO2
Inflammatory Bowel Disease: Postoperative Complications
- Bleeding
- Fluid and electrolyte imbalance
- Peritonitis
- Life-threatening inflammation
- Abscess formation
- Rigid, boardlike abdomen
- Nausea, vomiting
- Rebound tenderness
- Tachycardia
- Fever
Musculoskeletal trauma: Priority findings to report for a client who has a cast
- Monitor neurovascular status and collect data about pain
- Apply ice for 24-48 hr
- Handle a plaster cast with the palms, not fingertips
- Avoid setting the cast on hard surfaces or sharp edges
- Ensure the area is cleaned and dried
- Tubular cotton web roll is placed over the affected area
- Elevate the cast above the level of the heart during the first 24 to 48 hr
- Drainage is seen: outlined, dated, and timed
Respiratory diagnostic and therapeutic procedures: Postoperative care following a Bronchoscopy
- Monitor from PACU
- Check LOC, gag reflex, ability to swallow
- Offer ice chips one reflex returns
- Monitor: productive cough, hemoptysis, hypoxemia
- Provide oral hygiene
- Encourage coughing and deep breathing every 2 hours
Benign Prostatic Hyperplasia: Teaching following prostatectomy
a. Instruct the client to report symptoms of infection.
b. Teach the client catheter care if he will be going home with one in place.
c. Tell the client to avoid heavy lifting and strenuous activity for the prescribed period of time.
d. Instruct the client to avoid tub baths for at least 2 to 3 weeks.
e. Drink 12 or more 8oz. Of water each day
f. Avoid bladder stimulant. (caffeine or coffee)
g. If urine becomes bloody, stop the activity, rest and increase fluid intake.
Hyperthyroidism: Client response following a total thyroidectomy
- Speak as soon as waking up from anesthesia
- Cough and breathe deeply
- Notify charge nurse of any tingling sensation of the mouth, distal extremities, or muscle twitching
- Notify the surgeon of incision drainage, swelling, or redness
- Monitor hypothermia, lethargy, and weight gain
Middle and Inner Ear Disorders: Reinforcing teaching following a tympanoplasty
- No Shampoo for one week
Patient teaching about chest physiotherapy
- Coughing
- Deep breathing
- Use of incentive spirometer
- Chest percussion
- Chest vibration
IV Therapy: Discontinuing an infusion following infiltration
- Stop the therapy
- Notify the provider immediately
- Warm compress the site
- Put pressure on the site as you remove the IV
Electrolyte imbalances: Identifying the location to Elicit a Chvostek Sign
- Sign of hypocalcemia
- Contraction or twitching of the facial muscle produced by tapping on facial nerve on specific
Pulmonary Embolism: Expected Findings
Expected Findings
i) Dyspnea
Respiratory management and mechanical ventilation: Care of a client receiving mechanical
ventilation
ii) When the high pressure alarm goes off, suction the client
Angina and myocardial infarction: Evaluating client understanding of chest pain
iii) Apply the nitroglycerin patch to a hairless area.
iv) History: Chest pain
Infections of the renal and urinary system: reinforcing client teaching about urinary tract
infections
- Promote fluid intake
- Pee as soon as possible
- Urinate before and after sex
- Promote good hygiene
- Change tampons often
- Change undergarments often
- Wash and wipe
- Wipe front to back
Communicable diseases: expected findings with varicella
- Vesicles on the body
- Fever
- Malaise
- anorexia
Manifestations of Thyroid Storm
v) Increased Pulse and Blood Pressure
GI Therapeutic Procedures: Colostomy Teaching
vi) Empty colostomy bag before procedure
Skin Disorders: Teaching about psoriasis treatment
- Observe skin for thinning, striae, or hypopigmentation with high-potency corticosteroids
- Avoid use on face or in skin folds, and take periodic medication vacations.
- Use warm, moist, occlusive dressings of plastic wrap after applying the medication.
- Can be left in place up to 8 hour each day.
- Gloves
- Plastic garments
- Booties
COPD: Expected findings of Emphysema
- Dyspnea
- Productive cough (worst upon rising in the morning)
- Hypoxemia
- Crackles and wheezes
- Rapid and shallow respirations
- Use of accessory muscles
- Barrel chest or increased chest diameter
- Hyperresonance on percussion due to trapped air
- Irregular breathing pattern
- Thin extremities and enlarged neck muscles
- Dependent edema (r/t RHF)
- Clubbing of fingers and toes
- Pallor and cyanosis
- Low O2 Sat
Clients with allergic reaction:
Administer epinephrine.
Macular Degeneration effect/ manifestation:
Decreased Central Vision
Furosemide adverse effect:
Hypokalemia
Intravenous pump numbers are off:
Stop IV and reset pump
Chadwick sign:
Purple vagina
When there’s an increase flow rate of the client’s bladder:
Irrigate
Levels:
Sodium: 135-145
Potassium: 3.5-5.0
Calcium: 9-11
Phosphate: 2.5-4.5
Magnesium: 1.5-2.5
Chloride: 97-107
Digoxin: 0.5-2
Lithium: 0.8-1.4
Hgb: m: 14-18; f: 12-16
RBC:M- 4.7-6.1millions, F:4.2-5.4millions
WBC: 5,000-10,000
Platelets: 150,000-400,000
How to draw up long and short insulin:
Inspect for cloudy contaminants
Roll the vials
Insert air (NPH insulin)
Insert air (Regular)
Withdraw Regular
Withdraw and add NPH
When a nurse is intoxicated while caring for the clients:
Remove the nurse from clients
Use of inhalers:
Decreases bronchospasm
*If you are giving 15 units of insulin, be sure to inject 15 units of air before pulling an insulin
Client who has osteoarthritis:
Apply capsaicin cream QID
Client who is receiving continuous bladder irrigation after TURP; intervention:
Maintain a drainage flow rate to keep the urine diluted
Gastrostomy care:
Flush the tube with 60 mL of water
Client accuses nurse stole her money; therapeutic response
Tell me how you decided who took your money
Client has rubeola; what to implement?
Airbourne
Client is prescribed with home O2 therapy; instructions
Apply water-based lubricant around the nostrils
Prioritization of clients; who’s the priority?
Client who is at 36 weeks of gestation and reports painless vaginal bleeding
Receiving morphine thru PCA pump:
Increase fluid intake
Client has pneumonia; entries should the nurse include in the plan?
Bathing in the evening
Client taking montelukast:
Daily at bedtime
Metronidazole adverse effect:
Reddish-brown urine
