ATI comprehensive predictor STUDY THIS ONE

What can be delegated to Assistive personnel (AP)?
Click the card to flip 👆
1 / 198
Terms in this set (198)
A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP?
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
What is an agreement to keep promisesFidelityWhat is fairness in care delivery and use of resourcesJusticeWhat is avoidance of harm or injuryNon-maleficenceA nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. NonmalificienceAA nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. BeneficienceDA nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. NonmaleficenceCA nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. NonmalificenceDWhich of the following situations can be identified as an ethical dilemma? A. A nurse on a med surge unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney formCMost managers can be categorized asauthoritative, democratic, and laissez fairemakes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settingsAuthoritativeincludes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessaryDemocraticmakes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situationLaissez faireThe nurse should consider the hierarchy of human needs when prioritizing interventions, which are?- Physiological needs first (oxygen, shelter, food) - Safety & security needs (physical safety) - Love and belonging - Self esteem - Self actualizationThe ABC framework identifies, in order, the three basic needs for sustaining lifeAirway Breathing CirculationNurses must follow what code of standards in delegating and assigning tasksANA codes of standardsWhat values would a nurse possess to be a client advocate?- caring - autonomy - respect - empowermentWhat do the nurse need to keep in mind about the client when being their advocate?Client's religion & cultureWhen should planning discharge process begin? a. at time of admission b. 2 days after client is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge orderAWhat is an interdisciplinary team?A group of health care professionals from different disciplinesFill in the blank: 1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone.1 & 2 = collaborationWhat is the nurse's contribution to an interdisciplinary team?- knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems.A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.2A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 cc per hour.4The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 1. increased pulse rate. 2. decreased temperature. 3. fine tremors. 4. increased radioactive iodine uptake level.2A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head.3Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position her on her abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist her with heat application and ROM exercises.4The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient 1. with his neck in a midline position and the head of the bed elevated 30°. 2. side-lying with his head extended and the bed flat. 3. in high Fowler's position with his head maintained in a neutral position. 4. in semi-Fowler's position with his head turned to the side.1The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to 1. use a new sterile catheter each time he performs a catheterization. 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. 3. perform the catheterization procedure every 8 hours. 4. limit his fluid intake to reduce the number of times a catheterization is needed.2A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication five minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture.4A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment.1A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. reestablishes a trusting relationship with his/her other parent. 3. verbalizes that s/he is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.3An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks."2After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes2A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium.1An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. 2. remain at the client's side to provide reassurance. 3. tell the client the name of the medication and its effects. 4. monitor the anticholinergic effects of the medication.1The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.1The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.3A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.3The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of 1. red meat and shellfish. 2. cottage cheese and ice cream. 3. fruit juices and milk. 4. fresh fruits and uncooked vegetables.1A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.3A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."3The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is 1. before breakfast. 2. with dinner. 3. with food. 4. at hs.4. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 1. increasing respiratory difficulty seen with exertion. 2. cough productive of a large amount of thick, yellow mucus. 3. peripheral edema and anorexia. 4. twitching of extremities.3The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.2The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? 1. The client advances the cane 18 inches in front of her foot with each step. 2. The client holds the cane in her left hand. 3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the cane with her elbow flexed 60°.2A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.1The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply1A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live."4A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.4. The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations.1An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-residue diet. 2. lie on her unoperated side. 3. exercise her arms and legs. 4. cough and deep breathe.4Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.4An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position.1Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep.1The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for a duration of 6-9 months.4The nurse's INITIAL priority when managing a physically assaultive client is to 1. restrict the client to the room. 2. place the client under one-to-one supervision. 3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area of other clients to prevent harm.3A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be 1. confused with cold, clammy skin and a pulse of 110. 2. lethargic with hot, dry skin and rapid, deep respirations. 3. alert and cooperative with a BP of 130/80 and respirations of 12. 4. short of breath, with distended neck veins and a bounding pulse of 96.1The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.1When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.3The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.2A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.4A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0mg/dL. 4. The patient's hemoglobin is 8.5g/dL.3A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says she feels pressure against her diaphragm when the baby moves.1After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.2After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.2The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room.4A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via facemask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside.3What type of infectious diseases are required to be reported to the health department?- severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA)What is the process of taking a telephone order from a provider?Patient name, drug, dose, route, frequency read back for accuracyA nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygieneA B EA charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visitingDA nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheterAA nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's roomAA nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedsideAWhich of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant handBA nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his careCA nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20AA nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly"CA nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chlorideCA nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each stepCWhich of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardiaAA nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the woundCA nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbetDA nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? a) assess for bladder distention after 6 hr b) encourage the client to use a bed pan in the supine position c) restrict the clients intake of oral fluids d) pour warm water over the clients perineumDWhen caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.3Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.2Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.3A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.2During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.2 3 4The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.3The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.1When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers4What are some ways to identify a patient before giving a medication?The Joint Commission requires 2 client identifiers be used when administering medications. - clients name - assigned identification number - telephone number - birth date or other personal-specific identifiers. Bar code scanners may be used to identify clientsWhat are some things to teach about home safety with elderly patients?- Removing items that could cause the client to trip, such as throw rugs and loose carpets - Placing electrical cords and extension cords that against a wall behind furniture - Making sure that steps and sidewalks are in good repair - Placing grab bars near the toilet and in the tub or shower and installing a stool riser - Using a non-skid mat in the tub or shower - Placing a shower chair in the shower - Ensuring that lighting is adequate both inside and outside of the homeA nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.B C EA nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. ____ Passive smoking ____ Carbon monoxide poisoning ____ Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking.C A BWhen performing nasotracheal suctioning what technique should be used?Sterile asepsis bc the trachea is considered sterile and prevents infectionsA nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. BradypneaAWhat do you do when a client has a seizure- lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movementseclusion and restraints-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 minWhat position is good to use for a patient who is at high risk for a pressure ulcer30 degree lateral position is recommended for clients at risk for pressure ulcershealth promotion (injury prevention-suffocation): infant (birth-1 yr)-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothinghypotension is classified with a reading below normal;systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilationWhat temperature should pork be cooked at160 degreesWhat is the safest way to thaw out frozen foodsIn the refrigeratorWhat are the precautions for vancomycin resistant enterococcusStandard precautions including hand washing and gloving should be followedWhat does a newborns poop look likeIf your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistencyWhat is appropriate for an adolescent in the hospital?Puzzles and booksWhat is the proper nutrition during pregnancy- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida - green leafy vegetables and brown riceWhat should be avoided during pregnancyDo not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your babyWhat is the most appropriate method for contraception for an adolescentIUD or implantIf a patient has anorexia nervosa and works out constantlyAllow them to workout and continue their regimenWhat medications can be taken to help with smoking cessationBupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix)What are the five stages of griefdenial anger bargaining depression acceptancediscrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual lossanticipatory griefinvolves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of timedysfunctional griefSigns for meningococcemiaVomiting, febrile, petechial rash (unstable)Levothyroxine effectsUsed to restore client's metabolic rate * Toxic effects = heat intolerance, Tachycardia, Weight loss, HypertensionMultiple Sclerosis PatientMitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration * Hair Loss = emotional distress * Amenorrhea = emotional distressMalnourished COPD patients(1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soupWhich grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair"Anger stageWhich Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again"Bargaining StageHow should you respond when client wants to discontinue dialysis"What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeuticWhat should the nurse do when one member of a support group expresses anger repeatedly?Focus more on the group members who have a positive outlook (Speak to group member privately to uncover source of anger)What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis)Long term effects of NSAIDS (Ibuprofen)Gastric Ulcerations, perforations, hemorrhage, hypertensionAlcohol Use Manifestations of WithdrawalBody burns 0.5 oz of alcohol per hour * Withdrawal appears within 4-12 hours * Irritability + Tremors + Anxiety * Nausea + Vomiting + HA * Diaphoresis * Sleep Disturbances * TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)When does Discharge planning begin?At AdmissionCase Management nursing involves:*Decreasing cost by improving client outcomes * Providing education to optimize health participation * Advocating for services + client's rightsWhat is bipolar disorder?Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.What comorbidities may be observed with a patient who is bipolar?Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD.What therapy will be useful for patients with bipolar?Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior.What kind of medications are indicated for abstinence maintenance of alcohol?Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)Teaching points for naltrexone (Vivitrol)?Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen.A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals.BA patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intakeCA client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrantDWhich outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.APatients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Warm moist skin d) PolyuriaAThe nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stoolBAfter teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) LiverCA nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth c) Regular diet d) Clear liquidsBBladder retraining for the treatment of urge incontinence:• Use timed voidings to increase intervals between voidings/decrease voiding frequency. • Perform pelvic floor (Kegel) exercises. • Perform relaxation techniques. • Offer undergarments while the client is retraining. • Teach the client not to ignore the urge to void. • Provide positive reinforcement as client maintains continence. • Eliminate or decrease caffeine drinks. • Take diuretics in the morning.what are normal creatinine levels? what are normal BUN levels?0.8-1.4 mg/dL 8-25 mg/dLWhat are total serum protein values (normals)6-8 g/dLDescribe pre-albuminthis is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks)what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a normal potassium serum level?17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia)what are good sources of folic acid?Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils.Sources of potassiumbeans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananaswhat is important about the diet of someone taking ACE inhibitors?can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)Taking Coumadin. Which foods should the client limit?Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, pruneswhat is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs?37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uLwhat foods should you avoid if you have diverticulitis?avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber)When taking MAOI's, limit your consumption ofthyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar...At what age does bone loss begin with osteoporotis what are normal Calcium levels?at age 35 (women) 8.6-10 mg/dLA positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration ofcalcium gluconate (because hypocalcemia causes Chvostek's sign)What are the S/S of lithium toxicity? (depakote for bipolar disorder)fine hand tremors, mild GI upset, slurred speech and muscle weaknessa nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoidAspirina nurse responsible for a client receiving a antihypertensive medication is toteach the client to change position slowly to avoid dizziness or faintinga client should receive a dose of flumazenil ( romazicon) to treat symptoms ofbenzodiazepine overdosea nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teachingI will tell my doctor before I stop taking the medicationa nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include1. change position slowly to minimize dizziness 2. chewing sugarless gum to prevent dry moutha client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ?what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the provider of client headache and ibuprofen usa client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medicationthrombocytes, amylase count and liver function testalcohol withdrawal heroin withdrawal nicotine withdrawal alcohol abstinence opioid over dosechlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram ( antabuse) naloxone (narcan)a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this clientorthostatic hypotensiona nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this clientthe nurse should monitor the client respiratory depressiona client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the providerserum potassium 5.2a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at riskToxic level of digoxina nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teachingi should decrease the amount of calcium in my diet while taking the medicationA nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity?* Verapamil (Calan)Adverse effect of VerapamilAvoid grapefruit juiceInteraction of diuretics and ACE inhibitorsexcessive reduction in blood pressure and symptomatic hypotension or hyperkalemiaWhat can prevent MI, stroke, or death in high-risk patientsRamiprilWhat to monitor for when taking enoxaparin (lovenox)Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reportedWhat are the therapeutic effects of protamineAntidote to severe heparin overdose + Reversal of heparin administered during proceduresHow to prevent adverse effects of oxycodonecan cause respiratory depression. What is the nursing intervention and/or client education ? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol).opioid agonists can cause Constipation What is the nursing intervention and/or client education ?Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation.Adverse effects of ferrous sulfateconstipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth.Baclofen (Lioresal) therapeutic outcome:Decrease the frequency and severity of muscle spasms (MS).What is the difference between respiratory acidosis and respiratory alkalosis?Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.Bowel elimination how to get a specimen collectionCollect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine.Identifying manifestations of transient ischemic attackssymptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke.Musculoskeletal congenital disordersMonitor skin for breakdown areas and prevent pressure sores.The nurse caring for a child in Buck's skin traction will keep the:Child pulled up in bedWhere should the cath bag be placed when urinary catheterizationMake sure the catheter bag/system is at a level below the client's bladder to avoid reflux.What are the signs and symptoms of fluid volume deficitloss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension.What is the nursing action for dehiscenceCover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's .