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Basics Final Exam Review questions...
Terms in this set (120)
You discover a chest tube has accidentally been dislodged from the client's chest. What action do you implement first?
Cover site with an occlusive dressing
How much fluid is infused in a soaps suds enema?
500 to 1000 mL
What type of oxygen delivery is used when a specific percentage of oxygen delivery is desired?
When using a cooling blanket, what assessment other than body temperature is important to assess?
How many calories did a client consume from 200 g of carbohydrates?
A post-operative client with an indwelling urinary catheter has an urine output less than 30 mL/hr. What action will you take first?
Notify the physician
A client tells you she wants life-sustaining treatments withheld should she experience a coma. What document do you suggest she complete?
A client with stage 2 breast cancer asks if she promises to improve her diet and exercise habits do you think her cancer will heal without chemotherapy. Which stage of grieving is she exhibiting?
A client is experiencing respiratory alkalosis due to hyperventilation. What treatment will you implement?
Breathing into a paper bag
A client has a pain pump. You note that he received 24 mg of pain medication but pushed the button to receive 40 mg. He is complaining his pain is not relieving well. What action will you implement?
Add a basal rate
What are the 4 components of pulmonary hygiene?
- Turn, cough, deep breathe;
- Volumetric incentive spirometry;
- Increased ambulation;
- Adequate hydration;
When should a person experiencing difficulty sleeping see a healthcare provider?
When it impacts activities of daily living
What time of day will you plan to obtain a sputum specimen?
What is the most important safety measure for a new mother to implement to protect her newborn from sustaining an accidental injury?
- Car seat,
- Testing the heat of formula and bath water
You note your client is occasionally disoriented. How will you position the bed when you leave the room?
Lowest position with top side rails up
A client is experiencing constant bubbling in the water seal chamber of the chest tube. What does this indicate?
What is the nursing diagnosis for a client experiencing Cheyne-Stroke respirations?
Ineffective breathing pattern
How do you know if crutches are fitted correctly?
Elbows flexed 20 to 30 degrees when hands on the hand grip
You plan on taking an oral temperature of a client but the client is drinking iced tea when you enter the room. How long will you need to wait to take the temperature?
20 to 30 minutes
You are infusing enteral feedings at 100 mL/hr. Each can of feeding has 250 mL. How many cans will you add when the feeding reservoir is empty?
3 to 4 cans
What is the common name for 5% dextrose in water and 0.45% sodium chloride?
How much dextrose in fluid indicates the fluid should be infused through a central line instead of a peripheral one?
Greater than 10%
You charted information on the wrong chart. How do you correct your mistake?
Edit and correct within the system that will document the previous entry and your correction with your ID included.
How are contractures prevented?
Range of motion exercises
A Hispanic client asks for information on how to maintain normal weight. What question will you ask first?
What are your current diet and exercise habits?
You are preparing to transfer a client with right sided weakness from bed to a wheelchair. Where would you place the wheelchair?
Near the client's left leg (stronger side)
How many mL of fluid intake is 100 mL of ice chips?
How many mL of normal saline would you use to irrigate an NG tube?
What damage can be done by TED hose?
Achilles tendon damage
A client receiving a blood transfusion starts to complain of itching. What action will you take first?
Stop the transfusion
Prior to suctioning a client's endotracheal tube, what action will you implement?
Hyperoxygenate the client
What body system is most affected by changes in sodium?
What body system is most affected by changes in potassium?
A client has an ABG result of:
What type of compensation is occurring?
A client is restrained with a vest restraint due to being disoriented following an amputation of his left leg. What assessment is priority for you to perform regarding safe restraint use?
The physician requests you discontinue a feeding tube on a terminally ill client. The client does not have a living will or power of attorney. Who will you ask for permission to discontinue this tube?
Next of kin
The goal "expectorate secretions" fits with which nursing diagnosis?
Inadequate airway clearance
You maintained good aseptic technique during urinary catheter insertion. What other way could you harm the client during insertion?
Inflating the balloon in the urethra
What is the best way to treat phantom limb pain for a client who sustained a traumatic limb amputation during a motor vehicle crash?
Medicate with an analgesic
Kayexelate enemas are used for what purpose?
To lower serum potassium levles
When collecting a 24 hour urine specimen, how is the first voiding handled?
What interventions can you implement to prevent urgency incontinence?
- Decrease bladder irritants;
- Loose easy to maneuver clothing;
- Frequent daytime voiding;
- Decrease fluid intake after 6 at night
What do enzymatic creams do for a wound?
A client has ABG results of:
Which acid base imbalance is occurring?
A client who gets tired when bathing or performing other activities of daily living has which nursing diagnosis?
How many mL of residual will you tolerate on a continuous enteral feeding infusing at 100 mL/hr?
200 mL or less (2 hours of feeding or less)
What is the best way for you to assess if an NG tube is placed correctly?
Test the gastric pH
You are inserting an NG tube. What action will you implement to prevent aspirations during tube placement?
Place client in a high Fowler's position
Which type of suction requires sterile technique?
Lab results show a client has MRSA. Which transmission-based precaution will you implement?
What are the three main adverse effects of sedatives?
- Increase sedation,
- Increased confusion, and
- Daytime drowsiness
What are the three isotonic fluids?
- D5W, and
A client experiencing anxiety over a scheduled CT scan is demonstrating hyperventilation. What acid-base imbalance do you suspect is occurring?
A client with cardiomyopathy is at risk of postural hypotension. What safety measure will you recommend to the client?
Change positions slowly
A women identifying herself as a close family friend of your client asks why her surgery has been delayed. What would be the most appropriate response?
Ask the client
How would you get consent forms signed if a client indicates he understands the procedure but he can't write?
2 licensed nurses to witness verbal consent
An elderly client asks if you have a few minutes to talk with her. She then starts telling you about her fears of dying. What is the most therapeutic thing you can do while she is talking?
Sit silently and listen to her
You are receiving report on a client returning from surgery when another client pulls his alarm button indicating distress. What should you do?
Care for the distressed client first
You plan to teach a newly diagnosed client with diabetes mellitus about his insulin administration. What will you need to determine before you begin?
What are the four components of smoking cessation program?
- Quit date,
- Craving reduction therapy, and
- Behavior modification
A client with cancer is experiencing pain at a level of 7. The client received his regularly scheduled pain medication one hour ago. What pain relief measure will you implement now?
What fluid will you use to irrigate an NG tube?
After washing your hands, what can you do to prevent infection for a client receiving TPN?
Use aseptic technique when changing the dressings and handling the feedings and connections
A client on a full liquid diet received a tray with yogurt with blueberries, iced tea, cream soup and milk. Which item is not allowed and should be removed from the tray?
A client shows you she has blood in her urine that was not there earlier. What should you do first?
Assess for the source
An area of a client's arm is swollen and tender following infiltration of D51/2NS. What measure will you implement to reduce the pain and edema?
Apply a warm pack
How does the circulating nurse role differ from the scrub nurse role?
Circulating nurse is responsible for monitoring client response and aseptic technique
How many liters of oxygen would you place on a client with COPD?
2 to 3 L
If ice or heat are applied, how long are they left in place?
10 to 20 minutes
A client who lost her husband 6 months ago tells you that she needs to start taking better care of herself so that she can spend more time with her family. What stage of grieving is she experiencing?
An adult client who had a leg amputated a month ago is found crying because the hospital is out of chocolate milk. When questioned, he screams at you that "At least the hospital can do is keep the milk I like." Which stage of grieving is this client exhibiting?
Why do nurses perform evaluation as a part of the nursing process?
To determine the effectiveness of our interventions
What is the most effective way to prevent a confused client from falling due to getting out of bed unassisted?
Have family or a staff member at the bedside
What is a late sign of hypoxia?
What is a critical pathway?
Interdisciplinary plan of care
How is deep vein thrombosis prevented on a surgical client who cannot get out of bed?
TED hose or SCD hose
When removing personal protective equipment, which item do you remove first?
You find a client on the floor and he tells you he fell. The incident report asks for type of incident. What do you write?
"Found on floor and stated fell."
While feeding a client, you note she chokes when food is placed on the left side of her mouth but not on the right. What is her nursing diagnosis?
Risk for aspiration related to unilateral weakness
A client who had surgery four hours ago has a fever of 101.2 degrees fahrenheit. What action will you implement?
If you did not recognize a client's condition was deteriorating until it was too late, what type of law did you break?
A client has tea-colored urine and burning on urination. Which disorder do you suspect?
Urinary tract infection
You note fluctuation in the water-seal chamber of a client's chest tube when the client inhales and exhales. What will you do with this information?
A client with a diagnosis of paralytic ileus has an NG tube to suction. Prior to assessing bowel sounds, what action will you implement?
Turn off the suction
Before collecting a specimen from an infected wound, what action will you implement?
Clean wound with saline
A client receiving an opioid pain medication via a pain pump has a respiratory rate of 8 bpm. You suspect opioid-induced respiratory depression. After turning off the pump, which assessment should first implement to assess the client's sedation level?
A client returns from surgery and eight hours later has not urinated. What action will you implement first?
Assess for bladder fullness
A client is experiencing thirst, dry skin, and a negative fluid balance following three days of vomiting. What is this client's nursing diagnosis?
Fluid volume deficit related to vomiting
A client is brought into the emergency department unconscious and bleeding heavily following a motor vehicle crash. The physician wants to take him to surgery immediately but there is no family available to give consent. Who else can give consent?
How much fluid did a client who lost 2 kg of weight lose?
You document on 11/30/2010 1300 Client's dressing to his left leg changed and wound is well-approximated with staples without redness or swelling and sign your name and title. What is wrong with this documentation.
Do not use the word client because it is about the client therefore assumed
You set an outcome that the client will improve ambulation. What is wrong with this outcome?
Not measurable or time specific.
How often should TED hose be removed?
Every shift for at least 30 minutes to an hour
The goal "establish normal effective respiratory pattern" fits with which nursing diagnosis?
Ineffective breathing pattern
A client receiving a soaps suds enema complains of abdominal cramping. What action should you take first?
Stop the infusion
You discover a client's chest tube has disconnected form the drainage delivery device and the device connection is grossly contaminated. What action will you implement first?
Place the end of the tube in a bottle of sterile water
A client is found unresponsive with a faint heart rate and slow respirations. What oxygen delivery device will you place on the client?
Non-rebreather or partial non-rebreather mask
If you place a non-rebreather mask on a client, how many liters of oxygen will you need to deliver?
Greater than 5 liters and typically 10 liters
How many mL of fluid intake did the client consume if she ate 4 oz of Jello?
If a client speaks a language you do not speak, which action should you take to communicate with the client?
Consult a medical translator
A client has wrists restrained due to pulling out tubes. Which actions are priority for the nurse to administer?
Order to continue restraints obtained each 24 hours, loosen restraints and assess skin and perform range of motion every 2 hours, use least restrictive restraint as possible, remove restraints promptly when need form them resolve
What abbreviations are on the do not use list?
U, IU, QD, QOD, X.0 mg, .X mg, MS, MSO4 and MgSO4
What is the best way to evaluate the effectiveness of patient teaching?
What assessments need to be made before performing patient teaching?
Patient's learning needs, motivation to learn, and health literacy
What actions can a nurse take to find an accurate list of a patient's home medications?
Have patient's family bring actual bottles to the hospital, call the patient's pharmacies, call the patient's physician offices
What are the components of a prescription?
- Patient identifiers,
- Drug name,
- Dose, route, frequency, duration
- Prescriber signature
When are the three safety checks of administering medications?
Removing from automated dispensing device, during preparation and once in the patient's room
What are the 9 rights of medication administration?
- Right patient,
- Right drug,
- Right dose,
- Right route,
- Right time,
- Right documentation,
- Right reason,
- Right to refuse, and
- Right to know
Which pain scale is used for a 5 year old child?
Which pain scale is used when the patient cannot indicating a pain rating?
What are the adverse effects of long-term opioid use?
Constipation and Tolerance
How should patient's protect their dentures when cleaning them?
Pad the wash basin so if dropped into it the dentures won't crack
What is the difference between mechanical soft and soft diet?
Mechanical soft is easy to chew and
Soft is easy to digest
A fever during early recovery from surgery typically indicates which condition?
What is a splint pillow?
Small pillow or folded blanket used to splint the abdomen as coughing to support the incision during coughing
What does the term "ablative" mean?
To take away
What are the adverse effects of corticosteroids?
- Fluid retention,
- Emotional lability,
- Fragile skin, bones, and blood vessels,
- Decreased immunocompetency,
- GI distress,
- Increased bleeding,
- Sense of well-being
What can cause a false positive hemoccult?
Red foods and Red meat
What position should patients be placed to receive enema?
Left side Sims
What causes false pulse oximeter readings?
Decreased hemoglobin, cold extremities, nail polish
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