Week 4 Flashcards
Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient?
A. Do not massage any reddened areas on the patient’s skin.
B. Be sure to wash the patient’s face with soap.
C. Disconnect the intravenous tubing when changing the gown.
D. Wear gloves if necessary.
A. Do not massage any reddened areas on the patient’s skin.
The nurse has washed a patient’s arms. Which area should the nurse wash next?
A. Hands
B. Chest
C. Abdomen
D. Legs
A. Hands
A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient’s safety?
A. Use the call light to ask someone else to bring a washcloth.
B. Raise all four side rails on the patient’s bed.
C. Make sure the call light is within the patient’s reach.
D. Raise the bed to its highest position.
C. Make sure the call light is within the patient’s reach.
Which patient should not have his or her feet soaked during a complete bed bath?
A. A patient with arthritis
B. A patient who has just complained of shoulder pain
C. A patient with diabetes mellitus
D. A patient who is nauseated
C. A patient with diabetes mellitus
The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient’s eyes?
A. Remove eye crusts with soapy water.
B. Avoid closing the patient’s eyes.
C. Use eye patches or shields taped in place.
D. Tape the patient’s eyelids closed.
C. Use eye patches or shields taped in place.
The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse’s follow-up?
A. “I’ll ask for assistance if I need help positioning her.”
B. “I’ll see if she’s up to the care right now.”
C. “I’ll let you know if I notice any signs of redness or discharge.”
D. “I’ll be sure to use hot, soapy water, since she has been incontinent.”
D. “I’ll be sure to use hot, soapy water, since she has been incontinent.”
[Warm water should be used]
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent
D. Dorsal recumbent
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, “I can do that myself.” Which action would be the priority?
A. Provide all the necessary supplies and linen for this task.
B. Assess the patient’s ability to perform proper perineal care.
C. Ensure that the patient has privacy while performing perineal care.
D. Document any complaints of irritation or pain in the perineal area.
B. Assess the patient’s ability to perform proper perineal care.
How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing it.
C. By cleansing the patient’s labia from the pubic area toward the rectum.
D. By using warm water to cleanse the patient’s entire perineal area.
C. By cleansing the patient’s labia from the pubic area toward the rectum.
The nurse is delegating a female patient’s perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP’s safety while performing this care?
A. Wear sterile gloves.
B. Wear clean gloves.
C. Wear an isolation gown.
D. Use hot water.
B. Wear clean gloves.
Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?
A. Wear clean gloves during care.
B. Assess the patient’s ability to provide self-care.
C. Encourage the patient to report any pain originating from the catheter.
D. Monitor the amount of urine in the drainage bag to prevent overflow.
A. Wear clean gloves during care.
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse’s follow-up?
A. Assisting the patient into the supine position in bed.
B. Cleansing the tip of the penis with a circular motion, starting at the meatus.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
D. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
A male patient receiving perineal care tells the nurse “It has started to hurt a little down there.” What is the nurse’s best response?
A. “When did you start experiencing the pain?”
B. “Rate the pain on a scale of 1 to 10.”
C. “I’ll assess your perineal area for the possible cause of the pain.”
D. “Would you like some pain medication before I continue with your care?”
A. “When did you start experiencing the pain?”
The nurse has delegated a male patient’s perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse’s follow-up?
A. “I will check to see if he cleans himself well.”
B. “I will let you know if I see any redness or drainage.”
C. “I will ask him if he is experiencing any pain in that area.”
D. “I will be sure to use hot, soapy water to be sure he’s clean.”
D. “I will be sure to use hot, soapy water to be sure he’s clean.”
What is the primary reason for performing perineal care on a male patient with incontinence?
A. To provide comfort and a relaxed, refreshed feeling
B. To promote personal hygiene while minimizing perineal odor
C. To remove all microorganisms from the patient’s perineal area
D. To reduce the risk of skin breakdown in the patient’s genital and perineal area
D. To reduce the risk of skin breakdown in the patient’s genital and perineal area
The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change?
A. Keep the head of the bed no lower than a 30-degree angle.
B. Fold a pillow in half and place it under the patient’s head.
C. Lower the bed to a flat position and place two pillows beneath the patient’s head.
D. Ask another caregiver to hold the patient’s head during the bed change.
A. Keep the head of the bed no lower than a 30-degree angle.
The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change?
A. “You’ll need to apply Standard Precautions during this task.”
B. “Soiled linen should be rolled toward your uniform.”
C. “Soiled linen should be kept away from your uniform.”
D. “Keep the linen bag at the foot of the bed.”
A. “You’ll need to apply Standard Precautions during this task.”
Which action ensures that a patient will not have unnecessary pain during a linen change?
A. Discontinue the bed change if the patient expresses or displays physical signs of pain.
B. Explain the procedure to the patient before beginning the linen change.
C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed.
D. Postpone the bed change if the patient reports having physical pain before you begin.
C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed.
The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made?
A. Lower the head of the bed
B. Raise the side rails
C. Apply the topsheet
D. Discard the soiled linen in the linen bag
B. Raise the side rails
What will the nurse do right after placing a clean topsheet on the patient?
A. Make a cuff with the top of the sheet.
B. Make a horizontal toe pleat.
C. Tuck the remaining portion of the sheet under the foot of the mattress.
D. Remove the bath blanket.
D. Remove the bath blanket.
The nurse who is preparing to make an unoccupied bed should do what to ensure his or her personal safety?
A. Put on sterile gloves.
B. Place the call light within the nurse’s reach.
C. Place the bed at a comfortable working height.
D. Place a laundry bag on the bedside chair.
C. Place the bed at a comfortable working height.
The nurse is preparing to change the soiled linen of a patient’s unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms?
A. Perform hand hygiene and apply clean gloves.
B. Place fresh linen on a clean bedside table or chair.
C. Put soiled linen in a pillow case before placing in a hamper.
D. Roll soiled linen together with the dirty sides toward the center.
A. Perform hand hygiene and apply clean gloves.
What would the nurse instruct the nursing assistive personnel (NAP) to do before making an unoccupied bed if the mattress is soiled?
A. Wash the mattress with hot water.
B. Wipe off moisture with antiseptic solution, and dry thoroughly.
C. Flip the mattress.
D. Apply a waterproof pad over the soiled area.
B. Wipe off moisture with antiseptic solution, and dry thoroughly.
The nurse is reviewing placement of an unfitted bottom sheet with nursing assistive personnel (NAP) assigned to make an unoccupied bed. What should the nurse include in this teaching?
A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.
B. Keep enough material to miter the lower mattress corners.
C. Apply the drawsheet on the cleaned mattress first.
D. Make the top of the bed first, moving to the bottom of the bed.
A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.
When making an unoccupied bed, where would the nurse place a waterproof pad?
A. Directly on the mattress.
B. Beneath the drawsheet.
C. Over the bottom sheet.
D. Over the top sheet.
C. Over the bottom sheet.
To which patient might the nurse apply a physical restraint?
A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
C. A 74-year-old patient confined to bed who is at risk of pressure ulcers.
D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours?
A. To try a less restrictive type of restraint if a more confining restraint has proved effective
B. To double-check the size by inserting one finger between the wrist and the restraint
C. To check the skin integrity and range of motion of the wrist
D. To comply with Joint Commission standards
C. To check the skin integrity and range of motion of the wrist
What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint?
A. “Tell me if the patient’s pulse changes.”
B. “Tell me if the skin under the restraint becomes abraded or raw.”
C. “Let me know if you think she’s ready for them to come off.”
D. “Let me know if the patient needs anything for pain.”
B. “Tell me if the skin under the restraint becomes abraded or raw.”
The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient’s wife says, “I don’t like him being tied down in the bed?”
A. “I’m sure you don’t want him to fall again.”
B. “Can you suggest an alternative?”
C. “What did you do to prevent him from falling when he was at home?”
D. “We will try all other alternatives before using physical restraints.”
D. “We will try all other alternatives before using physical restraints.”
When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the NAP do?
A. Check the patient’s blood pressure and pulse before smoothing the gown
B. Untie the restraint and smooth the patient’s gown
C. Put on the call light for help
D. Ask the patient what specific help she would like
B. Untie the restraint and smooth the patient’s gown
Which statement demonstrates the patient’s ability to perform incentive spirometry correctly?
A. The patient inhales slowly and deeply.
B. The patient inhales rapidly.
C. The patient exhales rapidly.
D. The patient holds a breath for 15 seconds
A. The patient inhales slowly and deeply.
The RT walks into a postoperative patient’s room with an incentive spirometer and the patient asks, “What is the purpose of that?” What is the most appropriate response describing the purpose of incentive spirometry?
A. It administers aerosolized medications.
B. It prevents postoperative pulmonary complications.
C. It measures the patient’s peak flow
D. It improves expiratory flow.
B. It prevents postoperative pulmonary complications.
An RT is assessing the patient’s ability to perform incentive spirometry correctly by viewing a return demonstration. When is additional patient education needed?
A. When the patient examines the sputum expectorated
B. When the patient creates a complete seal over the mouthpiece
C. When the patient holds a breath for 5 seconds after maximum inhalation
D. When the patient performs a series of short inspirations
D. When the patient performs a series of short inspirations
A patient had a preoperative inspiratory capacity volume measurement of 6000 ml, which was equal to the patient’s predicted value before an appendectomy. What is the minimum acceptable postoperative volume to be achieved with an incentive spirometer?
A. 1000 ml
B. 2000 ml
C. 4000 ml
D. 5000 ml
B. 2000 ml
Rationale: Spirometry is not recommended for patients with a vital capacity of less than 10 ml/kg or an inspiratory capacity less than one third of predicted. The patient performed 6000 ml before surgery; therefore, one third of predicted would be 2000 ml. The patient may not return completely to baseline in the postoperative period. The patient probably will not exceed baseline after surgery.
A patient with COPD is recovering from postoperative abdominal surgery. The prescribing practitioner has ordered an incentive spirometer to decrease the chance of pneumonia. Which is an unexpected long-term outcome?
A. Shortness of breath after the use of the incentive spirometer
B. Correct patient demonstration of use of the incentive spirometer
C. Improved breath sounds after the use of the incentive spirometer
D. Patient achievement of target volume and number of repetitions per hour after the use of the incentive spirometer
A. Shortness of breath after the use of the incentive spirometer
While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit?
Radial and apical pulse
Apical and carotid pulse
Radial and brachial pulse
Apical and temporal pulse
Radial and apical pulse
A client arrives at a health clinic reports, “I am here to have my tuberculin skin test read.” The nurse notes a 7-mm indurated area at the injection site. Which nurse’s statement describes this result?
“The result indicates that you have active tuberculosis.”
“The result indicates you are infected with the tuberculosis organism.”
“The result indicates there are no tuberculin antibodies in your system.”
“The result indicates you have a secondary infection related to the tuberculin organism.”
“The result indicates you are infected with the tuberculosis organism.”
An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis.
A client weighed 210 pounds (95.2 kg) on admission to the hospital. After 2 days of diuretic therapy, the client weighs 205.5 pounds (93.2 kg). Which numerical value reflects the liters of fluid excreted by the client? Record your answer using a whole number.
2
One liter of fluid weighs approximately 2.2 pounds (1 kg); therefore a 4.5-pound (2 kg) weight loss equals approximately 2 liters.
For the client with a closed chest tube drainage system connected to suction, which assessment finding requires additional evaluation by the nurse?
A column of water 20 cm high in the suction control chamber
75 mL of bright red blood in the drainage collection chamber
An intact occlusive dressing at the insertion site
Constant bubbling in the water-seal chamber
Constant bubbling in the water-seal chamber
Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client’s chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client’s chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the pleural cavity, and the health care provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.
When the nurse completes a thorough assessment to identify the reason for a client’s anxiety, which critical thinking attitude is involved in this situation?
Discipline
Confidence
Responsibility
Thinking independently
Discipline
The nurse shows discipline in collecting a thorough assessment to identify the source of the client’s anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.
When assessing risk factors, which question would the nurse ask a client who has developed pneumonia?
“Are you diabetic?”
“Have you ever had pneumonia?”
“What do you use for contraception?”
“Do you have a history of intravenous [IV] drug abuse?”
“Are you diabetic?”
Chronic diseases such as diabetes are a risk factor for developing infections such as pneumonia. Inquiring about the client’s pneumonia history provides additonal information regarding the client’s knowledge but does not let the nurse understand the client’s risk factors. Contraception would be explored in sexual barrier devices for sexually transmitted infections. IV drug abuse would be explored to assess risk of exposure to blood-borne pathogens such as Hepatitis B.
During a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall?
Apply restraint to prevent ambulating without assistance
Discontinue all medications to remove the risk of polypharmacy
Assess the circumstances of the fall, including feelings and setting
Require family members to remain at the bedside to watch over the client
Assess the circumstances of the fall, including feelings and setting
The circumstances of the fall, including feelings and setting, should be explored and documented to understand risk of falls for this client. Fall history alone does not warrant use of restraint. The nurse consults with the health care provider on polypharmacy but does not discontinue medications independently. The family is not required to remain at the bedside but is encouraged to understand fall risk.
Upon entering the examination room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse?
Ask if there are concerns at home.
Call the client later to ensure safety.
Find a way to interview the client in private.
Assume the client is nervous in medical settings.
Find a way to interview the client in private.
Abuse is suspected when a client seems fearful of another person, and the nurse would find a way to interview the client in private. Asking about concerns at home should not be done in front of the spouse. Calling the client later does not address a possible immediate threat to the client’s safety. The nurse would investigate the safety of the client, not assume nervousness.
Upon entering an examination room for assessment of a confused client, which action would the nurse take?
Perform an assessment quickly.
Plan a focused physical assessment.
Skip the examination until the client is reoriented.
Leave the room to find the health care provider.
Plan a focused physical assessment.
A focused assessment is the most common and efficient physical examination. The nurse would not rush through an assessment because of confusion. The nurse would not skip the assessment because of confusion. The nurse would never leave a confused client unattended.
When preparing to assess a client with Clostridium difficile, which piece of personal protective equipment would the nurse put on before entering the client’s room?
Head covering
Clear eye mask
Full plastic gown
N95 respiratory mask
Full plastic gown
A client with Clostridium difficile should be on contact precautions to avoid the spread of the spores, so the nurse would wear a full plastic gown that is disposed of once the assessment is complete. A head covering, eye mask, and N95 respiratory mask are not necessary protective devices in the assessment of a client with Clostridium difficile.
When preparing to assess a client with active tuberculosis, which piece of personal protective equipment would the nurse put on before entering the client’s room?
Isolation gown
Surgical mask
Shoe covers
N95 respiratory mask
N95 respiratory mask
Active tuberculosis places a client on airborne precautions in accordance with which the nurse must wear an N95 respiratory mask to prevent personal respiratory exposure to the infectious droplets. An isolation gown, surgical mask, or shoe covers are not necessary protective devices in the assessment of a client with active tuberculosis, nor would they be sufficient to protect the nurse from infection.
While collecting a client’s urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia?
Malabsorption
Bladder cancer
Diabetic ketoacidosis
Urinary tract infection
Urinary tract infection
A strong ammonia odor in the urine can indicate that the client has a urinary tract infection, or possibly renal failure. Malabsorption can cause particularly foul-smelling stools in an infant. The ammonia odor does not indicate bladder cancer. Diabetic ketoacidosis usually causes a sweet/fruity odor on the breath.
A strong _______________ odor in the urine can indicate that the client has a urinary tract infection, or possibly renal failure.
ammonia
Diabetic ketoacidosis usually causes a ____________ odor on the breath.
sweet/fruity
A client weighs 150 lb and is 5 feet 7 inches tall. Which numerical value reflects this client’s body mass index (BMI)? Record your answer using two decimal places.
Body mass index (BMI) can be calculated by dividing the client’s weight in kilograms by the height in meters squared. A client who weighs 150 lb (68 kg) and stands 5 feet 7 inches (1.7 m) tall will have a BMI of 23.53: 68/1.7 2 = 23.53.
While providing care for a client with heat stroke, the nurse measured and noted the temperature as 39°C. Which temperature would the nurse document in Fahrenheit? Record your answer and round to tenths
Celsius is converted to Fahrenheit by multiplying the Celsius reading by 9/5 and adding the product to 32. In this case, the calculation is: (9/5)(39) + 32 = 102.2.
Which condition would the nurse suspect upon finding a bluish coloration of the skin during an assessment?
Anemia
Liver disease
Heart disease
Autoimmune disease
Heart disease
A bluish discoloration of the skin indicates cyanosis. This condition may be caused by increased amounts of deoxygenated hemoglobin, which may be due to heart disease or lung disease. In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin. In clients with liver disease, the skin appears yellow or orange due to increased deposits of bilirubin. In autoimmune diseases, the skin will lose its pigmentation.
In clients with anemia, the skin has a _________ due to a reduced amount of oxyhemoglobin
pallor
After conducting a falls risk assessment education session for the staff and observing falls risk assessments on the unit, which staff action needs review for corrective action?
Using a fall risk assessment tool
Assessing the environment for fall hazards
Inquiring about the client’s history of falls
Delegating fall assessments to assistive personnel
Delegating fall assessments to assistive personnel
Falls risk cannot be delegated. The nurse needs to be the person to complete falls risk assessment, not assistive personnel. Use of a falls risk assessment tool, assessing the environment for hazards, and exploring the client’s history of falls are all appropriate actions for fall risk assessment
Which assessment item needs to be documented on a client with restraints? Select all that apply. One, some, or all responses may be correct.
Pulse near the restrained area
Temperature of the restrained area
Convenience of restraining the client
Skin integrity surrounding the restraint
Behavior leading to the need for restraint
Pulse near the restrained area
Temperature of the restrained area
Skin integrity surrounding the restraint
Behavior leading to the need for restraint
After presenting information about falls risk assessments to nursing staff, which participant’s statement needs review for corrective action?
“We will assess every admission to the unit.”
“We will implement a valid falls risk assessment tool.”
“We will apply yellow wrist bands to high-risk clients.”
“We will use the admission fall assessment for the entire stay.”
“We will use the admission fall assessment for the entire stay.”
Falls risk assessment should be updated routinely through discharge, because fall risk may change throughout the hospital stay. Falls risk assessment should be completed on every client with a valid falls risk tool. High-risk fall clients should be identified.
After reviewing otoscope use for assessment of the ear with the nursing staff, which participant’s response reflects safe follow-up care for when earwax covers the tympanic membrane?
“I will leave the wax in place.”
“I will use a cotton-tipped swab to remove the wax.”
“I will insert the tip of a hemostat to remove the wax.”
“I will perform warm water irrigation to remove the wax.”
“I will perform warm water irrigation to remove the wax.”
Earwax in front of the tympanic membrane should be removed for assessment and proper hearing, and irrigation with warm water is a safe way to remove the wax. The wax should not be left in place, because the tympanic membrane cannot be seen and it may disrupt normal hearing. Cotton-tipped swabs and pointed objects like the tip of a hemostat should not be placed into the ear canal because they can cause damage.
An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which statement describes the nurse’s responsibility in this situation?
The nurse’s judgment was adequate, and the client was treated accordingly.
The possibility of tetanus was not foreseen because the client was immunized.
Nurses would routinely administer immunization against tetanus after such an injury.
Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.
Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.
The nurse’s data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse’s assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a “tetanus-prone” wound, like a puncture from a rusty nail, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.
_____________ is a food-borne disease and may be due to the ingestion of milk products, seafood, or salad. The symptoms of infection include abdominal cramps and severe diarrhea and can occur 12 hours after ingestion
Shigellosis
For an older adult client with dementia who developed dehydration as a result of vomiting and diarrhea, which assessment information best reflects the client’s fluid balance?
Skin turgor
Intake and output results
Client’s report about fluid intake
Blood lab results
Blood lab results
Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the older adult client because it is generally decreased with age. Intake and output results provide data only about fluid balance but do not present a comprehensive picture of the client’s fluid and electrolyte status; therefore, this is not the best answer. The client’s report about fluid intake is subjective data in general and not reliable because this client has dementia and consequent memory problems.
In the emergency department, the nurse assessed a client who is unconscious, experiencing severe bleeding due to a motor vehicle accident, and in hypovolemic shock. At which site would the nurse obtain the client’s pulse rate? Select all that apply. One, some, or all responses may be correct.
Apical
Carotid
Brachial
Femoral
Popliteal
Carotid
Femoral
Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. Both the apical and brachial pulses may not be palpable in a client with hypovolemic shock. The popliteal site is used to assess the status of the circulation in the lower leg.
Which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for three days?
Presence of dry skin
Loss of body weight
Decrease in blood pressure
Altered general appearance
Loss of body weight
Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb (1 kg). Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.
Which scenario would contribute to health disparities?
An English-speaking critical care nurse assesses a Hispanic client in a coma.
An English-speaking nurse plans the nursing procedures for a Black Latino client.
An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing.
An English-speaking nurse conducts an admission interview of a Puerto Rican immigrant with limited knowledge of English.
An English-speaking nurse conducts an admission interview of a Puerto Rican immigrant with limited knowledge of English.
While conducting an assessment, the nurse finds the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. Which temperature would the nurse associate with these findings?
29°C (84.2°F)
33°C (91.4°F)
36°C (96.8°F)
38°C (100.4°F)
33°C (91.4°F)
A body temperature in the range of 36°C (96.8°F) to 38°C (100.4°F) is normal. When skin temperature drops below 35°C (95.0°F), the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30°C (86.0°F) represents severe hypothermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client’s temperature is most likely 33°C (91.4°F).
Which client would have a health promotion nursing diagnosis?
The client with acute pain due to appendicitis
The client who is willing to take a 30-minute walk daily
The older adult client with dementia admitted to the health care facility
The client with reduced cognitive ability while recovering from surgery
The client who is willing to take a 30-minute walk daily
A health promotion nursing diagnosis is a clinical judgment of an individual’s desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client’s response to a particular health condition. A risk nursing diagnosis describes an individual’s response to health conditions that may develop in a vulnerable individual. The older adult client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls.
The nurse assesses a client’s pulse and documents the strength of the pulse as 3+. Which pulse strength does this documentation refer to?
Diminished
Normal
Full
Bounding
Full
The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.
The nursing student, under the supervision of the registered nurse (RN), plans to perform a pulse assessment. While preparing to assess the client, the RN asks the student to check the apical pulse after assessing the radial pulse. Which rationale supports the RN’s request?
The client may have a dysrhythmia.
The client may have physiologic shock.
The client underwent surgery earlier in the day.
The client may have peripheral artery disease.
The client may have a dysrhythmia.
A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the RN would advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.
Which related factor would the nurse attach to a nursing diagnosis?
Prostatectomy
Trauma of incision
Acute renal failure
Knee replacement surgery
Trauma of incision
The related factor or etiology of a nursing diagnosis is always within the nursing domain. The nurse must ensure the related factor is a condition responding to nursing interventions. Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostatectomy is a medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also a medical condition. Nursing interventions should be directed toward behaviors or conditions that can be managed or treated by the nurse. Knee replacement surgery is a medical condition that cannot be managed by nursing interventions
When assessing a client reporting shortness of breath, which activity best ensures the nurse obtains accurate and complete data to prevent a nursing diagnostic error?
Assess the client’s lungs.
Assess the client for pain.
Obtain details of smoking habits.
Ask about the onset of shortness of breath.
Assess the client’s lungs.
The nurse would assess the client’s lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client’s chest excursion. The nurse would review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes shortness of breath; however, the client’s statement is subjective data. All subjective data must be supported by measurable objective data.
Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?
The nurse understands the client has pain due to a tracheostomy.
The nurse identifies the client is anxious about the cardiac catheterization.
The nurse realizes the client has diarrhea and needs the bedpan frequently.
The nurse identifies the client is not aware of perineal care and has impaired skin integrity.
The nurse identifies the client is not aware of perineal care and has impaired skin integrity.
The nurse observes the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct because it will help enhance the client’s health outcomes. The nursing diagnosis would identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain after the trauma of the surgical incision. The nursing diagnosis would contain the client’s response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure, rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse would plan nursing interventions after identifying the client’s problem. The nurse would identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.
The registered nurse (RN) measures the client’s blood pressure as 130/80 mm Hg. When the unlicensed assistive personnel (UAP) measured the same client’s blood pressure, the measurement was 120/90 mm Hg. Which rationale would explain the measurement difference? Select all that apply. One, some, or all responses may be correct.
Poor fitting of the cuff
Inflating the cuff too slowly
Deflating the cuff too quickly
Inflating the cuff inadequately
Applying the stethoscope too firmly
Poor fitting of the cuff
Deflating the cuff too quickly
Poor fitting of the cuff or deflating the cuff too quickly causes false low systolic and false high diastolic readings. Inflating the cuff too slowly results in false high diastolic readings. Inadequately inflating the cuff yields false low systolic readings. Applying the stethoscope too firmly against antecubital fossa yields false low diastolic readings.
ANAL CANAL
- Outlet of the gastrointestinal tract
- Layers of muscles and sphincters – ensures tightly closed canal
- Highly vascular
-Sphincters – 2 present (internal and external – voluntary control)
RECTUM
- Distal portion of the large intestines
- Review of the anatomy
PROSTATE
- Lies in front of the anterior wall of the rectum
- Surrounds the bladder neck and urethra
- With increased age, the prostate enlarges due to hormonal changes (BPH)
Benign Prostatic Hyperplasia
MALE GENITOURINARY Anatomy review
FEMALE GENITOURINARY SYSTEM: EXTERNAL STRUCTURES REVIEW
-Vulva, or pudendum
-Mons pubis
-Labia majora
- Labia minora
- Frenulum or fourchette
-Clitoris
-Vestibule
-Urethral meatus
-Skene’s glands
-Vaginal orifice
-Hymen
-Bartholin’s glands
-Vulva, or pudendum
-Mons pubis
-Labia majora
- Labia minora
- Frenulum or fourchette
-Clitoris
-Vestibule
-Urethral meatus
-Skene’s glands
-Vaginal orifice
-Hymen
-Bartholin’s glands
FEMALE GENITOURINARY SYSTEM: INTERNAL STRUCTURES - REVIEW
-Vagina
-Cervix
-Squamocolumnar junction
-Anterior fornix
-Posterior fornix
-Rectouterine pouch, or cul-de-sac of Douglas
-Uterus
-Fallopian tubes
-Vagina
-Cervix
-Squamocolumnar junction
-Anterior fornix
-Posterior fornix
-Rectouterine pouch, or cul-de-sac of Douglas
-Uterus
-Fallopian tubes
