Green Light Focused Review

Question 1

If wound dehiscence or evisceration occurs

Answer 1

call for help, stay with the client, cover the wound with a sterile towel or dressing that is moistened with sterile saline, do not attempt to reinsert organs, place in supine position with hips and knees bent, monitor for shock, and notify the provider immediately.

Question 2

Laboratory Findings of Fluid Volume Excess

Answer 2

Decreased Hct, electorlytes, BUN, and creatinine. ABG’s: Respiratory alkalosis, decreased CO2 (less than 35 mm Hg), Increased pH (above 7.45)

Question 3

Laboratory Findings for Fluid Volume Deficit

Answer 3

Urine specific gravity greater than 1.030, hypothermia

Question 4

Maintaining cardiac output in burn patients

Answer 4

• Provide assistance initiating intravenous access using a large-bore needle. If a large area of the body is burned, a central venous catheter is inserted.
• Fluid replacement is important during the first 24 hr.
• Rapid fluid replacement is needed during the emergent phase to maintain tissue perfusion and prevent hypovolemic (burn) shock.
• Fluid resuscitation is based on individual client needs (evaluation of urine output, cardiac output, blood pressure, status of electrolytes).
• Isotonic crystalloid solutions, such as 0.9% sodium chloride or lactated Ringer’s, are used.
• Colloid solutions, such as albumin, or synthetic plasma expanders (Hespan, Plasma-Lyte), can be used after the first 24 hr of burn recovery.
• Maintain urine output of 30 mL/hr (0.5 to 1.0 mL/kg/hr).
• Be prepared to assist in administering and monitoring transfusion of blood products as needed.

Question 5

Teamwork and Collaboration (first choice of action)

Answer 5

• Request appropriate referrals (social services, support groups, medical equipment, and physical, speech, and occupational therapy).

Question 6

Client Education for hyponatremia

Answer 6

• Encourage clients to weigh themselves daily and to notify the provider of a 1- to 2-lb gain in 24 hr, or 3 lb gain in 1 week.
• Instruct clients to follow sodium guidelines, read food labels to check sodium content, and keep a daily record of sodium intake.
• Encourage clients to weigh themselves daily and to notify the provider of a 1- to 2-lb gain in 24 hr, or 3 lb gain in 1 week.
• Instruct clients to follow sodium guidelines, read food labels to check sodium content, and keep a daily record of sodium intake.
• Encourage clients to weigh themselves daily and to notify the provider of a 1- to 2-lb gain in 24 hr, or 3 lb gain in 1 week.
• Instruct clients to follow sodium guidelines, read food labels to check sodium content, and keep a daily record of sodium intake.

Question 7

Objective Data of Infant Hypoglycemia

Answer 7

• Poor feeding
• Jitteriness/tremors
• Hypothermia
• Diaphoresis
• Weak shrill cry
• Lethargy
• Flaccid muscle tone
• Seizures/coma
• Irregular respirations
• Cyanosis
• Apnea
• Poor feeding
• Jitteriness/tremors
• Hypothermia
• Diaphoresis
• Weak shrill cry
• Lethargy
• Flaccid muscle tone
• Seizures/coma
• Irregular respirations
• Cyanosis
• Apnea

Question 8

Nursing Care of patient with alcohol withdrawal

Answer 8

• Personal views, culture, and history can affect the nurse’s feelings regarding substance use and addictive disorders. The nurse must self-assess his own feelings, which can be transferred to the client through body language and the terminology the nurse uses when collecting data from the client. An objective, nonjudgmental approach by the nurse is imperative.
• Safety is the primary focus of nursing care during acute intoxication or withdrawal.
• Maintain a safe environment to prevent falls. Implement seizure precautions as necessary.
• Provide close observation for withdrawal symptoms, possibly one-on-one supervision. Physical restraint should be a last resort.
• Orient the client to time, place, and person.
• Maintain adequate nutrition and fluid balance.
• Create a low-stimulation environment.
• Administer medications to treat the effects of intoxication or to prevent or manage withdrawal.
• Monitor for covert substance use during the detoxification period.

Question 9

Administering Liquid Medication to an Infant

Answer 9

• Hold the infant in a semi-reclining position similar to a feeding position.
• Administer the medication in the side of the mouth in small amounts. This allows the infant or child to swallow.
• Only use the droppers that come with the medication for measurement.
• Stroke the infant under the chin to promote swallowing while holding cheeks together.
• Hold the infant in a semi-reclining position similar to a feeding position.
• Administer the medication in the side of the mouth in small amounts. This allows the infant or child to swallow.
• Only use the droppers that come with the medication for measurement.
• Stroke the infant under the chin to promote swallowing while holding cheeks together.

Question 10

Nursing care of a client with DVT

Answer 10

• Encourage the client to rest.
• Facilitate bed rest and elevation of the extremity above the level of the heart as prescribed. (Avoid using a knee gatch or pillow under knees.)
• Administer intermittent or continuous warm moist compresses as prescribed.
• Do not massage the affected limb.
• Provide thigh-high compression or antiembolism stockings.

Question 11

Caring for a client following a parathyroidectomy

Answer 11

• Keep the client in a high-Fowler’s position. Support head and neck with pillows. Avoid neck extension.
• Check surgical dressing and back of neck for excessive bleeding. Be aware that respiratory distress can occur from compression of trachea due to hemorrhage.
• Respiratory distress also can occur due to edema. Ensure that suction equipment and tracheostomy supplies are immediately available. Humidify air, assist to cough and deep breathe, and provide oral and tracheal suction if needed.
• Check for laryngeal nerve damage by asking the client to speak as soon as awake from anesthesia and every 2 hr thereafter.
• Administer medication to manage pain. Reassure the client that discomfort will resolve within a few days.
• Hypocalcemia and tetany can occur if parathyroid glands are damaged or removed.
• Indications are tingling of toes or around mouth, and muscle twitching. Check for positive Chvostek’s and Trousseau’s signs. Ensure that IV calcium gluconate or calcium chloride are immediately available.
• If no drain is in place, prepare the client for discharge the day following surgery as indicated. However, if a drain is in place, the surgeon will usually remove it, along with half of the surgical clips, on the second day after surgery. The remaining clips are removed the following day before discharge.

Question 12

Mucositis (stomatitis)

Answer 12

inflammation of tissues in the mouth, such as the gums, tongue, roof and floor of the mouth, and inside the lips and cheeks.

Question 13

Nursing actions for mucositis

Answer 13

• Examine the client’s mouth several times a day, and inquire about the presence of oral lesions.
• Document the location and size of lesions that are present. Lesions should be cultured and reported to the provider.
• Avoid using glycerin-based mouthwashes or mouth swabs. Nonalcoholic, anesthetic mouthwashes are recommended.
• Administer a topical anesthetic prior to meals.
• Discourage consumption of salty, acidic, or spicy foods.
• Offer oral hygiene before and after each meal. Use lubricating or moisturizing agents to counteract dry mouth.
• Examine the client’s mouth several times a day, and inquire about the presence of oral lesions.
• Document the location and size of lesions that are present. Lesions should be cultured and reported to the provider.
• Avoid using glycerin-based mouthwashes or mouth swabs. Nonalcoholic, anesthetic mouthwashes are recommended.
• Administer a topical anesthetic prior to meals.
• Discourage consumption of salty, acidic, or spicy foods.
• Offer oral hygiene before and after each meal. Use lubricating or moisturizing agents to counteract dry mouth.

Question 14

Client education for mucositis

Answer 14

• Encourage the client to rinse mouth with a solution of half 0.9% sodium chloride and half peroxide at least twice a day, and to brush teeth using a soft-bristled toothbrush.
• Instruct client to take medications to control infection as prescribed (nystatin [Mycostatin], acyclovir [Zovirax]).
• Encourage the client to eat soft, bland foods and supplements that are high in calories (mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt, bananas, and breakfast mixes).
• Encourage the client to rinse mouth with a solution of half 0.9% sodium chloride and half peroxide at least twice a day, and to brush teeth using a soft-bristled toothbrush.
• Instruct client to take medications to control infection as prescribed (nystatin [Mycostatin], acyclovir [Zovirax]).
• Encourage the client to eat soft, bland foods and supplements that are high in calories (mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt, bananas, and breakfast mixes).

Question 15

Adverse effect of acetylcysteine (Mucomyst, Acetadote)

Answer 15

• Aspiration and bronchospasm when administered orally
• Monitor clients for manifestations of aspiration and bronchospasm. Stop medication immediately and notify the provider.

Question 16

Poison prevention for children

Answer 16

• Keep toxic agents out of reach of children.
• Lock cabinets containing potentially harmful substances.
• Do not take medication in front of children.
• Discard unused medications.
• When giving a child medication, do not tell them it is candy.
• Use non-mercury thermometers.
• Eliminate lead-based paint in the environment.
• Encourage hand hygiene prior to eating.
• Do not store food in lead-based containers.

Question 17

What foods can decrease anticoagulant effects with excessive intake?

Answer 17

Foods high in vitamin K, such as dark green leafy vegetables (lettuce, cooked spinach), cabbage, broccoli, Brussels sprouts, mayonnaise, canola, and soybean oil

Question 18

Tyramine-rich foods include?

Answer 18

aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein dietary supplements, soups, soy sauce, some beers, and red wine.

Question 19

What causes increased bleeding when taken with fluoxetine?

Answer 19

Fluoxetine suppresses platelet aggregation and thus taking NSAIDs or anticoagulants with fluoxetine increases the risk of bleeding.

Question 20

How long should clients wait before starting an SSRI after stopping an MAOI?

Answer 20

Clients should stop taking MAOIs for 14 days prior to starting an SSRI.

Question 21

Adverse effects of CHOLINESTERASE INHIBITORS for management of myasthenia gravis.

Answer 21

• Excessive muscarine stimulation as evidenced by increased gastrointestinal (GI) motility, increased GI secretions, bradycardia, and urinary urgency
• Cholinergic crisis (excessive muscarinic stimulation and respiratory depression from neuromuscular blockade and CNS depression.

Question 22

Promoting sleep habits for older adults:

Answer 22

• Help clients establish and follow a bedtime routine.
• Limit waking clients during the night.
• Help with personal hygiene needs or a back rub prior to sleep to increase comfort.
Instruct clients to:
• Exercise regularly at least 2 hr before bedtime.
• Arrange the sleep environment for comfort.
• Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
• Limit fluids 2 to 4 hr before bedtime.
• Engage in muscle relaxation if anxious or stressed.

Question 23

What are major sources of Vit D?

Answer 23

Fish, fortified dairy products, sunlight.

Question 24

Maintenance for G Tube

Answer 24

Flush the tubing with 20 to 30 mL of warm water every 4 hr for continuous infusion, after returning residual formula into the stomach, and before and after bolus feedings and each medication administration.

Question 25

Client education for homonymous hemianopsia

Answer 25

If the client has homonymous hemianopsia (loss of the same half of the visual field in both eyes), instruct the client to use a scanning technique (turning head from the direction of the unaffected side to the affected side) when eating and ambulating.

Question 26

Traction care

Answer 26

Traction, countertraction, and frictional force are used to align, immobilize, and reduce muscle spasms associated with certain fractures. Through the use of a forward-pulling force and a backward force, adding or removing weight controls the degree of force applied to maintain traction and alignment. The type of traction used depends on the fracture, age of the client, and associated injuries.

Question 27

Skin Traction

Answer 27

Skin traction uses a pulling force that is applied by weights (may be used intermittently). Using tape and straps applied to the skin along with boots and/or cuffs, weights are attached by a rope to the extremity (Buck, Russell, Bryant traction).

Question 28

Skeletal Traction

Answer 28

Skeletal traction uses a continuous pulling force that is applied directly to the skeletal structure and/or specific bone. A pin or rod is inserted through or into the bone. Force is applied through the use of weights attached by rope. Skeletal traction (90°/90° traction) allows the client to change positions without interfering with the pull of the traction and decreases complications associated with immobility and traction.

Question 29

Balanced suspension traction

Answer 29

Balanced suspension traction suspends the leg in a flexed position. The hip and hamstring muscles are relaxed.

Question 30

Halo traction

Answer 30

Halo traction (cervical traction) uses a halo-type bar that encircles the head. Screws are inserted into the outer table of the skull. The halo is attached to either bed traction or rods that are secured to a vest worn by the client.

Question 31

Nursing actions for traction care

Answer 31

• Maintain body alignment.
• Provide pharmacological and nonpharmacological interventions for the management of pain and muscle spasms.
• Notify the provider if the client experiences severe pain from muscle spasms that is unrelieved with medications and/or repositioning.
• Monitor neurovascular status.
• Routinely monitor the client’s skin integrity and document findings.
• Inspect pin sites for pain, redness, swelling, drainage, or odor. Provide pin care per facility protocol.
• Check for changes in elimination, and maintain usual patterns of elimination.
• Ensure that all the hardware is tight and that the bed is in the correct position.
• Maintain weights so that they hang freely and the ropes are free of knots. Do not lift or remove weights unless prescribed and supervised by the provider.
• Ensure that the wrench to release the rods is attached to the vest when using halo traction in the event that CPR is necessary.
• Move the client in halo traction as a unit without applying pressure to the rods. This will prevent loosening of the pins and pain.
• Consult with the provider for an overbed trapeze to assist the client to move in bed.
• Provide range of motion and encourage activity of nonimmobilized extremities to maintain mobility and prevent contractures.
• Encourage deep breathing and use of incentive spirometry.
• Promote frequent position changing within restrictions of traction.
• Remove sheets from the head of the bed to the foot of the bed, and remake the bed in the same manner
• Maintain body alignment.
• Provide pharmacological and nonpharmacological interventions for the management of pain and muscle spasms.
• Notify the provider if the client experiences severe pain from muscle spasms that is unrelieved with medications and/or repositioning.
• Monitor neurovascular status.
• Routinely monitor the client’s skin integrity and document findings.
• Inspect pin sites for pain, redness, swelling, drainage, or odor. Provide pin care per facility protocol.
• Check for changes in elimination, and maintain usual patterns of elimination.
• Ensure that all the hardware is tight and that the bed is in the correct position.
• Maintain weights so that they hang freely and the ropes are free of knots. Do not lift or remove weights unless prescribed and supervised by the provider.
• Ensure that the wrench to release the rods is attached to the vest when using halo traction in the event that CPR is necessary.
• Move the client in halo traction as a unit without applying pressure to the rods. This will prevent loosening of the pins and pain.
• Consult with the provider for an overbed trapeze to assist the client to move in bed.
• Provide range of motion and encourage activity of nonimmobilized extremities to maintain mobility and prevent contractures.
• Encourage deep breathing and use of incentive spirometry.
• Promote frequent position changing within restrictions of traction.
• Remove sheets from the head of the bed to the foot of the bed, and remake the bed in the same manner

Question 32

Cane instructions

Answer 32

• Maintain two points of support on the ground at all times.
• Keep the cane on the stronger side of the body.
• Support body weight on both legs, move the cane forward 6 to 10 inches, then move the weaker leg forward toward the cane.
• Next, advance the stronger leg past the cane.

Question 33

Working Phase of Therapeutic Communication

Answer 33

• Maintain relationship according to the contract.
• Perform ongoing data collection to plan and monitor therapeutic measures.
• Facilitate the client’s expression of needs and issues.
• Encourage the client to problem-solve.
• Promote the client’s self-esteem.
• Foster positive behavioral change.
• Explore and deal with resistance and other defense mechanisms.
• Recognize transference and countertransference issues.
• Monitor and document the client’s problems and goals, and contribute to replanning as necessary.
• Support the client’s adaptive alternatives and use of new coping skills.
• Remind the client about the date of termination.
• Explore problematic areas of life.
• Reconsider usual coping behaviors.
• Examine own world view and self-concept.
• Describe major conflicts and various defenses.
• Experience intense feelings, and learn to cope with anxiety reactions.
• Test new behaviors.
• Begin to develop awareness of transference situations.
• Try alternative solutions.

Question 34

Immunizations for older adults:

Answer 34

• Immunizations against diphtheria, tetanus, pertussis, varicella, seasonal influenza, herpes zoster, and pneumococcal infections.

Question 35

Expected Growth and Development of Infants:

Answer 35

1 month
•	Demonstrates head lag
•	Has a grasp reflex
2 months
•	Lifts head off mattress when prone
•	Holds hands in an open position
3 months
•	Raises head and shoulders off mattress when prone
•	Only slight head lag
•	No longer has a grasp reflex
•	Keeps hands loosely open
4 months
•	Rolls from back to side
•	Places objects in mouth
5 months
•	Rolls from front to back
•	Uses palmar grasp dominantly
6 months
•	Rolls from back to front
•	Holds bottle
7 months
•	Bears full weight on feet
•	Moves objects from hand to hand
8 months
•	Sits unsupported
•	Begins using pincer grasp
9 months
•	Pulls to a standing position
•	Creeps on hands and knees instead of crawling
•	Has a crude pincer grasp
10 months
•	Changes from a prone to a sitting position
•	Grasps rattle by its handle
11 months
•	Walks while holding onto something
•	Places objects into a container
•	Neat pincer grasp
12 months
•	Sits down from a standing position without assistance
•	Tries to build a two-block tower without success

Question 36

Effectiveness of Newborn Breastfeeding:

Answer 36

• The newborn should nurse up to 15 to 20 min per breast. However, avoid educating clients regarding an expected duration of feedings. Clients should be educated on how to evaluate when the newborn has completed the feeding by noting the slowing of newborn suckling, a softened breast, or sleeping.

Question 37

Why would a nurse monitor clients receiving oxytocins?

Answer 37

30. Monitor clients receiving oxytocics (oxytocin [Pitocin], methylergonovine maleate [Methergine], and carboprost tromethamine [Hemabate]) to promote uterine contractions and to prevent hemorrhage.

Question 38

Prevention of thrombophlebitis

Answer 38

• Initiate early and frequent ambulation during the postpartum period.
• Instruct clients to avoid prolonged periods of standing, sitting, or immobility.
• Tell clients to elevate their legs when sitting and to avoid crossing their legs, which will reduce the circulation and exacerbate venous stasis.
• Recommend for clients to maintain fluid intake of 2 to 3 L of water each day from food and beverage sources to prevent dehydration, which causes circulation to be sluggish.
• Tell the client to discontinue smoking, which is a known risk factor.
• Measure the client’s lower extremities for fitted elastic thromboembolic hose to lower extremities. Provide thigh-high antiembolism stockings for the client at high risk for venous insufficiency.

Question 39

Management of thrombophlebitis

Answer 39

• Encourage clients to rest.
• Facilitate bed rest and elevation of the client’s extremity above the level of the heart. (Avoid using a knee gatch or pillow under knees.)
• Administer intermittent or continuous warm moist compresses.
• Do NOT massage the affected limb to prevent thrombus from dislodging and becoming an embolus.
• Monitor the client’s leg circumferences.
• Administer analgesics (nonsteroidal anti-inflammatory agents).
• Administer anticoagulants for DVT.

Question 40

Newborn Physical Assessment:

Answer 40

• Head circumference should be 2 to 3 cm larger than the chest circumference. A head circumference greater than or equal to 4 cm larger than the chest circumference can be an indication of hydrocephalus (excessive cerebral fluid within the brain cavity surrounding the brain). A head circumference less than or equal to 32 cm can be an indication of microcephaly (abnormally small head).
• Caput succedaneum (localized swelling of the soft tissues of the scalp caused by pressure on the head during labor) is an expected finding that may be palpated as a soft edematous mass and can cross over the suture line. Caput succedaneum usually resolves in 3 to 4 days and does not require treatment.
• Cephalohematoma is a collection of blood between the periosteum and the skull bone that it covers. It does not cross the suture line. It results from trauma during birth, such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears several hours or a day after birth and spontaneously resolves in 3 to 6 weeks.

Question 41

What is an iatrogenic infection?

Answer 41

An iatrogenic infection is a type of HAI resulting from a diagnostic or therapeutic procedure.

Question 42

Airborne precautions

Answer 42

Use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require:
• A private room.
• Masks and respiratory protection devices for caregivers and visitors.
• Use an N95 or high-efficiency particulate air (HEPA) respirator if the client is known or suspected to have tuberculosis.
• Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure.
• If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection.

Question 43

Droplet precautions

Answer 43

Droplet precautions protect against droplets larger than 5 mcg and travel 3 to 6 ft from the client (streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). Droplet precautions require:
• A private room or a room with other clients with the same infectious disease, ensuring that each client have their own equipment.
• Masks for providers and visitors

Question 44

Contact precautions

Answer 44

Contact precautions protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms). Contact precautions require:
• A private room or a room with other clients with the same infection.
• Gloves and gowns worn by the caregivers and visitors.
• Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag.

Question 45

Client Education for Prosthesis

Answer 45

• Explain to the client how to care for and wrap the residual limb and perform limb-strengthening exercises.
• Reinforce the proper application and care of the prosthesis to the client.
• Reinforce instructions with the client on how to safely transfer and use mobility devices and adaptive aids.
• Explain to the client how to manage phantom limb pain.

Question 46

Fire response in health care settings always follows the RACE sequence:

Answer 46

• R: Rescue – Rescue and protect clients in close proximity to the fire by evacuating them to a safer location. Ambulatory clients can walk unattended to a safe location.
• A: Alarm – Activate the facility alarm system.
• C: Contain – Contain the fire by closing doors and windows as well as turning off any sources of oxygen. Clients who are on life support are ventilated with a bag-valve mask.
• E: Extinguish – Extinguish the fire if possible using an appropriate fire extinguisher.

Question 47

Proper Body Mechanics while Lifting:

Answer 47

• Lifting
• Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles.
• Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and avoid strain on smaller muscles.
• When lifting an object from the floor, flex the hips, knees, and back. Get the object to thigh level, keeping the knees bent and the back straightened. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain.
• Use assistive devices whenever possible, and seek assistance whenever it is needed.

Question 48

Fall Prevention for Older Adult Client:

Answer 48

• Be sure the client knows how to use the call light, that it is in reach, and encourage its use.
• Respond to call lights in a timely manner.
• Use fall-risk alerts, such as ID wristbands per facility protocol.
• Provide regular toileting and orientation of confused clients as needed.
• Ensure adequate lighting.
• Orient the client to the setting (grab bars, call light) to ensure he knows how to use all assistive devices and can locate necessary items.
• Place clients at risk for falls near the nursing station.
• Ensure that bedside tables and overbed tables and frequently used items (telephone, water, tissues) are within the client’s reach.
• Maintain the bed in the low position.
• For clients who are sedated, unconscious, or otherwise compromised, the bed rails are kept up, and the bed is kept in the low position.
• Avoid the use of full side bed rails for clients who get out of bed or attempt to get out of bed without assistance.
• Provide the client with nonskid footwear and nonskid bath mats for use in tubs and showers.
• Use gait belts and additional safety equipment, as needed, when moving clients.
• Keep the floor free from clutter with a clear path to the bathroom (no scatter rugs, cords, furniture).
• Keep assistive devices nearby after validation of safe use by the client and family (glasses, walkers, transfer devices).
• Educate the client and family/caregivers on identified risks and the plan of care. Clients and family who are aware of risks are more likely to call for assistance.
• Lock wheels on beds, wheelchairs, and carts to prevent the device from rolling during transfers or stops.
• Use chair or bed sensors for clients at risk for getting up unattended to alert staff of independent ambulation.

Question 49

What does the the quality improvement process begin with?

Answer 49

The quality improvement process begins with identification of standards and outcome indicators based on evidence.

Question 50

Nurse’s Responsibilities with Informed Consent:

Answer 50

• Witnesses informed consent.
• This means the nurse must ensure that the provider gave the client the necessary information.
• Ensure that the client understood the information and is competent to give informed consent.
• Have the client sign the informed consent document.
• Notify the provider if the client has more questions or appears not to understand any of the information. The provider is then responsible for giving clarification.
• Document questions the client has, notification of the provider, reinforcement of teaching, and use of an interpreter.

Question 51

Autonomy

Answer 51

the ability of the client to make personal decisions, even when those decisions may not be in the client’s own best interest

Question 52

Beneficence

Answer 52

the care that is in the best interest of the client

Question 53

Fidelity

Answer 53

keeping one’s promise to the client about care that was offered

Question 54

Justice

Answer 54

fair treatment in matters related to physical and psychosocial care and use of resources.

Question 55

Nonmaleficence

Answer 55

the nurse’s obligation to avoid causing harm to the client

Question 56

Veracity

Answer 56

the nurse’s duty to tell the truth

Question 57

What are a nurse’s responsibilities?

Answer 57

42. Nurses have a responsibility to be advocates, and to identify and report ethical situations. Nurses must also decide beforehand where they personally stand with the ethical issue at hand.

Question 58

Priority Care for Respiration Illness:

Answer 58

• Place in side-lying position or on abdomen to facilitate drainage.
• Elevate head of bed when child is fully awake.

Question 59

44. Supervision occurs after delegation. A supervisor oversees a staff’s performance of delegated activities and determines if:

Answer 59

• Completion of tasks is on schedule.
• Performance was at a satisfactory level.
• Abnormal or unexpected findings were documented and reported.
• Assistance is needed to complete assigned tasks in a timely manner.
• Assignment should be re-evaluated and possibly changed.

Question 60

Priority Task for Assistive Personnel:

Answer 60

• Activities of daily living (ADLs)
• Bathing
• Grooming
• Dressing
• Toileting
• Ambulating
• Feeding (without swallowing precautions)
• Positioning
• Bed making
• Specimen collection
• Intake and output (I&O)
• Vital signs (on stable clients)

Question 61

METABOLIC ACIDOSES

Answer 61

• Results from excess production of hydrogen ions
• Diabetic ketoacidosis (DKA)
• Lactic acidosis
• Starvation
• Heavy exercise
• Seizure activity
• Fever
• Hypoxia
• Intoxication with ethanol or salicylates
• Inadequate elimination of hydrogen ions
• Kidney failure
• Inadequate production of bicarbonate
• Kidney failure
• Pancreatitis
• Liver failure
• Dehydration
• Excess elimination of bicarbonate
• Diarrhea, ileostomy
• Results in decreased HCO3-Increased H+ concentration

Question 62

S/S of metabolic acidosis

Answer 62

• Vital signs: bradycardia, weak peripheral pulses, hypotension, tachypnea
• Dysrhythmias
• Neurological: muscle weakness, hyporeflexia, flaccid paralysis, fatigue, confusion
• Respiratory: rapid, deep respirations (Kussmaul respirations)
• Skin: warm, dry, flushed

Question 63

Care for Client in Vaso-occlusive Crisis:

Answer 63

• Promote rest to decrease oxygen consumption.
• Administer oxygen as prescribed if hypoxia is present.
• Maintain fluid and electrolyte balance.
• Monitor I&O.
• Give oral fluids.
• Administer IV fluids with electrolyte replacement.
• Pain Management
• Use an interprofessional approach.
• Treat mild to moderate pain with acetaminophen (Tylenol) or ibuprofen (Advil). Manage severe pain with opioid analgesics.
• Implement comfort measures, such as warm packs to painful joints.
• Administer analgesics on a schedule to prevent pain.
• Assist with monitoring clients who are receiving blood products. Observe for manifestations of hypervolemia and transfusion reaction.
• Treat and prevent infection.
• Administer antibiotics.
• Perform frequent hand hygiene.
• Give oral prophylactic penicillin.
• Administer pneumococcal conjugate vaccine (PCV), meningococcal vaccine (MCV4), and yearly seasonal influenza vaccine.
• Monitor and report laboratory results

Question 64

Advanced Directives:

Answer 64

• The purpose of advance directives is to communicate a client’s wishes regarding end-of-life care should the client become unable to do so.
• The Patient Self-Determination Act (PSDA) requires that all clients admitted to a health care facility be asked if they have advance directives.
• A client without advance directives must be given written information that outlines her rights related to health care decisions and how to formulate advance directives.
• A health care representative should be available to help with this process.
• Two components of an advance directive are the living will and the durable power of attorney for health care.

Question 65

Metabolic acidosis

Answer 65

Decreased Co3 (

Question 66

Respiratory acidosis

Answer 66

Increased Co3 ( >45 ), Decreased pH (

Question 67

Respiratory alkalosis

Answer 67

Decreased Co2 ( 7.45 ), Hyperventilation

Question 68

Metabolic alkalosis

Answer 68

Increased Co3 ( >29 ), Increased pH ( >7.45)

Question 69

Po2

Answer 69

35-45 (35-45 minuets of carbon kills)

Question 70

Lithium

Answer 70

0.4-1.3

Question 71

pH

Answer 71

7.35-7.45

Question 72

POEM

Answer 72

Little Maggie is 1.5-2.5 years old (mg+). She ate 3.5-5 bananas (k+) and drank 8.5-10.5 ounces of milk (ca+). Then she took a 135-145 hour nap after swimming in the ocean (Na+).

Question 73

Co3

Answer 73

21-29

Question 74

BUN

Answer 74

7-18 (I need 7-18 hotdog buns.)