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PN 150 Facts and Terms, Hesi PN Practice Exam and Questions, Unit 6 - Foundations of Nursing Practice, Foundations of Clinical Nursing Practice Test 1, Foundations of Nursing Midterm, PN- Fundamentals, Foundations of Clinical Nursing Practice Test 1,...

Terms in this set (1991)

What is deontology?
rightness or wrongness of individual behaviors, duties, and obligations
What is utilitarianism?
behaviors are determined by either right or wrong based on consequences; "greatest amount of good for greatest amount of people"
What is autonomy?
Right to make own decisions; of sound mind
What is accountability?
the ability to answer for one's actions
What is advocacy?
Speaking on behalf of those who cannot speak for themselves.
What is beneficence?
Promoting the well being of individuals and the public (do good)
Ex- doing dental screenings
What is fidelity?
Keeping ones promises/commitments
What is nonmaleficence?
duty to do no harm
What is veracity?
Telling the truth and expecting it of others (trustfulness; integrity, determination)
What is the code of ethics for nurses?
It is a succinct statement of the ethical obligations and duties of every nurse
What is the most important piece of the code of ethics for nurses?
Provision 1.5
What is provision 1.5?
"The principle of respect for persons extends to all individuals with whom the nurse interacts."
What are ethical dilemmas?
situations that result in a conflict of 2 or more fundamental values.
What are some examples of ethical dilemmas?
peer reporting, end-of-life care, genetic testing, resource allocation, professional boundaries
What is the role of the ethics committee?
to prevent legal issues that often come from ethial dilemmas
What are constitutional laws?
laws based on the constitution
What are statutory laws?
laws created by legislative bodies such as congress and state legislatures
What are regulatory laws?
state boards granted power to make laws that govern their area
What are case laws?
laws determined by the outcome of court cases
What are the four D's of negligence/malpractice?
Duty
Dereliction
Damages
Direct cause
What is dereliction?
evidence that nurses actions did not meet standard of care
What is autocratic leadership?
The leader exerts complete control; direct commands.
What is democratic leadership?
it means that managers and workers work together to make a decision
What is laissez-faire leadership?
laid back with no direction
What is bureacratic leadership?
driven by policy and procedures
What are the 4 steps of Fayol's functions of management?
planning, organizing, directing, and controlling
What is Mintzberg's behavioral model?
managers are reactive not proactive; most of their time is spent in relations
What is Mintzberg's contemporary model?
Informational, People, Action
What is theory x?
Theory X assumes the average person dislikes work and will avoid it if possible. Therefore, people must be forced, controlled, and threatened with punishment to accomplish organizational goals.
What is theory y?
people want to find meaning in their work and will contribute in positive ways if the work is well designed
What are the principles of assigning tasks?
Know the nurse practice act in the state you are licensed
Cannot assign assessment, planning, evaluation, or accountability tasks
Person who it was assigned to cannot assign it to another person
What is the first principle of assigning tasks?
know the nurse practice act for the state in which you are licensed
What is the second principle of assigning tasks?
the nurse cannot assign tasks that involve assessment, planning, evaluation, or accountability
What is the third principle of assigning tasks?
the person to whom the assignment was given may not assign the task to another person
What should be assessed first before assigning a task?
patient stability
What are the 5 rights to safely assign tasks?
Task
Person
Circumstance
Communication
Supervision
What are torts?
wrongful acts that do not involve contracts
What are intentional torts?
1. Assault
2. Battery
3. Deceit and misrepresentation
4. Defamation
5. Invasion of property (patients BODY is the property)
6. False imprisonment
What are unintentional torts?
negligence and malpractice
What are the qualifications for medicare?
65+
10 year record in medicare covered employment
under 65 with end stage renal disease or totally disabled
What is a premium?
how much employee is paying for insurance plan
What is deductible?
yearly amount person must pay out of pocket for healthcare costs before insurance covers it
What is copayment?
amount insured person must pay at the time of service
What is coinsurance?
once deductible is met, it is the percentage of total bill paid by the insured person
What is capitation?
monthly fee a provider is paid for each covered patient
What are prospective payment systems?
they limit the amount paid by insurers, medicare, and Medicaid, so the amount paid for services is determined before giving care
What does the nurse practice act define?
nursing practice and establishes standards for nurses in each state
Who grants licensure to a nurse?
state boards of nursing
What is medicare part A?
hospital and durable medical equipment insurance
What is medicare part B?
out of hospital insurance
What is medicare part C?
managed care providers
What is medicare part D?
covers portion of prescription expenses
What is the most important treatment for aggression/anger?
ensure safety
What does dopamine do?
regulates pleasure and pain and plays a major role in addiction
When do early symptoms of alcohol intoxication and withdrawal appear?
6-12 hours after last drink
What are some early symptoms of alcohol withdrawal?
anxiety, irritability, aggression
What are some progressive symptoms of alcohol withdrawal?
increased BP and pulse, tremors, n/v/ diaphoresis, delirium tremors, hallucinations, seizures
How long can progressive alcohol withdrawal symptoms last?
2-5 days
What is Naltrexone (Revia)?
used to treat or eliminate alcohol cravings
What does Disulfiram cause?
unpleasant physical effects if alcohol is present in the body
What is methadone?
synthetic opiate that blocks craving for and effect of heroin
What is buprenorphine?
blocks the signs and symptoms of opioid withdrawal
What questions does the CAGE questionnaire ask?
have you ever felt that you need to cut down
have you been annoyed by people
have you felt guilty
have you ever used a substance as an eye opener in the morning
What is chiding?
scolding
What is providing "pat" answers?
"Oh everyone feels that way." " Oh everyone goes through this."
What percentage of medication errors are a cause of interpersonal communication?
60%
The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority?

A. Administer Prescribed stool softner
B. Administer prescribed PRN sleep medications.
C. Encourage breastfeeding to promote uterine involution
D. Encourage use of prescribed analgesic perineal sprays.
A. Administer Prescribed stool softner
The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area.

A. Duodenum
B. Gastric Pylorus
C. Liver
D. Spleen
C. Liver
A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?

A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia
B Amenorrhea
A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

A. Ask for a description of what happened during the night
B. Tell the daughter to talk to the unit's nurse manager
C. Reassure the daughter that the mother will get better care.
D. Explain that all the staff are doing the best they can.
A. Ask for a description of what happened during the night
A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

A. Autonomy vs. Shame and doubt.
B. Industry vs. Inferiority
C. intiative vs. Guilt
D. Trust vs. Mistrust
A. Autonomy vs. Shame and doubt.
Which action should the nurse implement in caring for a client following an electroencephalogram (EEG)?

A. Monitor the client's vital signs q4h
B. Assess for sensation in the client's lower extremities
C. Instruct the client to maintain bed rest for eight hours
D. Wash any paste from the client's hair and scalp
D. Wash any paste from the client's hair and scalp
The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpfull in preventing further development of the decubitus?

A. Encourage the client to eat foods high in protein
B. Assess the client with daily range of motion exercises
C. Teach the family how to perform sterile wound care
D. Ensure the IV fluids are administered as prescribed
A. Encourage the client to eat foods high in protein
What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?

A. Filtration
B. Diffusion
C. Osmosis
D. Active transport
C. Osmosis
The nurse is taking blood presure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position?

A. Slightly above the level of the heart
B. At the level of the heart
C. At the level of comfort for the client
D. Below the level of the heart
B. At the level of the heart
What are the final parameters that produce blood pressure? (select all that apply)

A. Heart rate
B. Stroke volume
C. Peripheral resistance
D. Neuroendocring hormones
E. Muscle tone
A. Heart rate
B. Stroke volume
C. Peripheral resistance
A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?

A. Appetite
B. Mood
C. Withdrawl
D. Energy level
B. Mood
Based on the documentation in the medical record, which action should the nurse implement next?

A. Give the rubella vaccine subcutaneously
B. Observe the mother breastfeeding her infant
C. Call the nursery for the infant's blodd type result
D. Administer Vicodin one tablet for pain
A. Give the rubella vaccine subcutaneously
A client is adminitted to the hosptial with a diagnosis of Pneumonia. Which intervetion should the nurse implement to prevent complications associated with Pneumonia?

A. Enourage mobilization and ambulation
B. Encourage energy conservation with complete bed rest
C. Provide humidified oxygen per nasal cannula
D. Restrict PO and intravenous fluids
A. Enourage mobilization and ambulation
The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only)
15
Which nursing activity is within the scope of practice for the practical nurse?

A. Complete an admission assessment in the normal newborn nursery.
B. Discontinue a central venous catheter that has become dislodged
C. Observe a client rotate the subcutaneous site for an insulin pump
D. Monitor a continous narcotic epidural for a postoperative client
C. Observe a client rotate the subcutaneous site for an insulin pump
After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel?

A. Identify the need for additional supplies to provide an extra dressing change
B. Provide perianal care and collect clean linens for the dressing change
C. Document the diarrhea that necessitates an additional dressing change
D. Position the client for access to the decubiti sties and remove dressings
B. Provide perianal care and collect clean linens for the dressing change
The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. Arrage the routes of administration in the order from fastest to slowest rate of absorption.

Subcutaenous
Intravenous
Intramuscular
Sublingual
Oral
Intravenous, sublingual, intramuscular, subcutaneous, oral.
A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene?

A. Offer to call the social worker to discuss the possiblity of abortion
B. Reassure the client that the infertility specialist can help
C. Express sorrow for the client's grief and offer to sit with her
D. Chart the vital signs and amount of vaginal bleeding
C. Express sorrow for the client's grief and offer to sit with her
A terminally ill male client and his family are requesting hospice care after discharge from the hosptial and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care?

A. Enhance symptom management to improve end of life quality
B. facilitates assisted suicide with the client's consent
C. Offers ways to postpone the death experience at home
D. Provide training for family members to care for the client.
A. Enhance symptom management to improve end of life quality
The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take?

A. Advsie the wife to shave against the hair growth
B. Teach the wife to keep the skin loose to avoid cuts
C. Encourage the wife to continue shaving her husband
D. Demonstrate the correct procedure to the wife
C. Encourage the wife to continue shaving her husband
To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply)

A. Posterior tibialis artery
B. Politeal artery
C. External femoral artery
D. Dorsalis pedis artery
E Radial artery
A. Posterior tibialis artery, D. Dorsalis pedis artery
The nurse is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain?

A. Smokes one pack of cigarettes daily
B. Drinks two beers daily
C. Works in a job that requires exposure to the sun
D. Eats while lying in bed
A. Smokes one pack of cigarettes daily
The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catherterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take?

A. Stand the client to void and run tap water within hearing distance before catheterizing the client.
B. Straight catheterize and if the residual uring volume is greater than 100 mL, clamp catheter
C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period.
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects?

A. Moon face, Slow wound healing, muscle wasting sodium and water retention
B. Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbital edema
D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
A. Moon face, Slow wound healing, muscle wasting sodium and water retention
The cervix is the opening into the uterine cavity. What is its function in reproduction?

A. Accepts and interprets signals of sexual stimuli
B. Secretes mucus to facilitate sperm transport
C. Serves as the site for union of ovum ans sperm
D. Receives the penis during intercourse
B. Secretes mucus to facilitate sperm transport
The nurse is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection?

A. 17-year-old who is sexually active simultaneously with numerous partners
B. 34-year old homosexual who is in a monogamous relationship
C. 30-year-old cocaine user who inhales and smokes drugs
D. 45-year-old who has received two blood transfusions in the past 6 months
A. 17-year-old who is sexually active simultaneously with numerous partners
The nurse is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate?

A. Conversion of irregular heart rate to regular heart rhythm
B. Pulse oximetry readings within normal range during activity
C. Peripheral pulse points with adequate capillary refill
D. Increase excercise tolerance without shortness of breath
A. Conversion of irregular heart rate to regular heart rhythm
An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide?

A. Use an over the counter stool softener when needed
B. Eat a high protein diet
C Increase the fluid intake in your diet
D. Decrease the fat content in your diet
C Increase the fluid intake in your diet
The nurse is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client?

A. Abnormal skin color changes in a client with dark skin cannot be determined
B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
C. The lips and mucus membranes of a client with dark skin are dusky in color
D. Cyanosis in a client with dark skin is seen in the sclera
C. The lips and mucus membranes of a client with dark skin are dusky in color
When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes uring flow into the tubing. What action is taken next?

A. Document the color and clarity of the urine
B. Insert the catheter an additional inch
C. Ask the client to breathe deeply and slowly exhale
D. Inflate the balloon with 5mL of sterile water
B. Insert the catheter an additional inch
A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?

A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain
B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
C. An infusion of medication in the spinal canal will block pain perception
D. The discharge of electricity will distract the client's focus on the pain
B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority?

A. Application of topical antibacterial cream
B. Use of careful hand washing technique
C. Administration of plasma expanders
D. Limiting visitors to the burned client.
B. Use of careful hand washing technique
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse?

A. The child looks at the floore when answering the nurse's questions
B. The mother's version of the injury is different from the child's version
C. The child has several abrasions on the chest and legs
D. The mother refuses to answer questions about family history
D. The mother refuses to answer questions about family history
A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?

A. Contact the pharmacy and request the prescribed form of aspirin
B. Instruct the client about the effects when given the medication
C. Administer the aspirin with a full glass of water or a small snack
D. Withhold the aspirin until consulting with the healthcare provider
C. Administer the aspirin with a full glass of water or a small snack
The nurse explains the 2-week dosage prescription of prednison (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule?

A. Decrease dosage daily as prescribed
B. Monitor oral temperature daily
C. Take the prednison with meals
D. Return for blood glucose monitoring in one week
C. Take the prednison with meals
The nurse is preparing to administer a 1.2mL injection to a 4-year-old. Which are the best sites to administer an IM injection? Select all that apply.

A. Vastus lateralis
B. Ventrogluteal
C. Dorsogluteal
D. Rectus femoris
E. Deltoid
A. Vastus lateralis
B. Ventrogluteal
C. Dorsogluteal
Which nonfood item is the most common cause of respiratory arrest in young children?

A. Broken rattles
B. Buttons
C. Pacifiers
D. Latex balloons
D. Latex balloons
A new mother is at the clinic with her 4-week old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2-months of age.

A. Turns from side to back and returns
B. Consistently returns smiles to mother
C. Finds hands and plays with fingers
D. Holds head up and supports weight with arms
B. Consistently returns smiles to mother
The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and teh infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?

A. The solution's rate is too rapid
B. The client has phlebitis
C. The infusion site is infected
D. The infusion site is infiltrated
D. The infusion site is infiltrated
The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?

A. Raise the bed to ensure the drainage bag remains off the floor
B. Attach the drainage bag to the side rail instead of the bed frame
C. Observe the appearance of the urine in the drainage tubing
D. Secure the tubing to the client's gown instead of his abdomen
C. Observe the appearance of the urine in the drainage tubing
In assisting a client to obtain a putum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

A. Advise the client that suctionin will be used to obtain another specimen
B. Re-instruct the client in coughing techniques to obtain another specimen
C. Provide the client a glass of water and mouthwash to rinse the mouth
D. Label the container and place the container in a biohazard transport bag
B. Re-instruct the client in coughing techniques to obtain another specimen
After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is.....

A. short of breath after a shower and has a hemoglobin of 8 grams
B. Beleeding from a finger stick and has a prothrombin time of 30 seconds
C. Febrile and has a WBC count of 14,000/mm3
D. Trembling and has a glucose level of 50 mg/dL
D. Trembling and has a glucose level of 50 mg/dL
4 hours after administration of 20U of regular insulin, the client becomes shake and diaphoretic. What action should the nurse take?

A. Encourage the client to excercise
B. Administer a PRN dose of 10U of regular insulin
C. Give the client crackers and milk
D. Record the client's reaction on the diabetic flow sheet
C. Give the client crackers and milk
The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?

A. Place a 4X4 wick in the stoma opening
B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
C. Cut the bag opening to the measurement of the stoma size
D. Administer a PRN antidiarrheal agent
C. Cut the bag opening to the measurement of the stoma size
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

A. Temperature of 100.8F
B. A pulse rate of 150 beats per minute
C. A respiratory rate of 10 breaths per minute
D. A blood pressure of 180/110
C. A respiratory rate of 10 breaths per minute
Following an open reduction of the tibian, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement?

A. Assess the client's hemoglobin to determine if the client is in shock
B. Call the surgeon and prepare to take the client back to the operating room
C. Outline the area with ink and check it q15 minutes to see if the area has increased
D. No action is required since postoperative bleeding can be expected
C. Outline the area with ink and check it q15 minutes to see if the area has increased
The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "what do these letters T1N0M0, stand for?" which response should the nurse provide first?

A. "The letters are used to predict the prognosis of the cancer or tumor."
B. "The letters stand for tumor size, node involvement and metastasis."
C. "Let me refer you to the charge nurse."
D. "Are you confused? Would you like to talk?"
B. "The letters stand for tumor size, node involvement and metastasis."
The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? what information should the nurse provide this client?

A. The client should bottle feed and pump her breast for 3 days following immunization
B. The vaccine is given to produce maternal antibodies before lactation occurs
C. The infant will receive immunization through the mother's breast milk
D. The client should not get pregnant for 3 months after immunization
B. The vaccine is given to produce maternal antibodies before lactation occurs
In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take?

A. Recheck the radial pulse in thirty minutes
B. Palpate the radial pulse for thiry seconds and double the rate
C. Count the apical pulse rate for sixty seconds
D. Compare the radial pulse rate bilaterally and record the higher rate.
C. Count the apical pulse rate for sixty seconds
Which structures are located in the subcutaneous layer of the skin?

A. Sebaceous and sweat glands
B. Melanin and Keratin
C. Sensory receptors and hair follicles
D. Adipose cells and blood vessels
D. Adipose cells and blood vessels
The nurse in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who i shelping with the care of several clients?

A. Measure the amount of a client's residual urine after voiding
B. Cleanse the perineal area of a client with urinary incontinence
C. Insert a straight catheter to obtain a urine specimen for culture
D. Provide catheter care for a client with a suprapubic catheter
B. Cleanse the perineal area of a client with urinary incontinence
A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively?

A. Across the eye from the bridge of the nose to the right temple
B. Longitudinally from the right forehead to the right cheek
C. From the mid-forehead over to the right zygomatic process
D. From the right lateral forehead surface to the medial nasal crease
B. Longitudinally from the right forehead to the right cheek
36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first?

A. Palpate the bladder for distention
B. Ask the client when her last bowel movement occurred
C. Catheterize the client and record the amount
D. Assess the amount of lochia
A. Palpate the bladder for distention
A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first?

A. Assess site of sting and remove stinger if present
B. Perform mini-mental status exam to assess level of consciousness
C. Determine respiratory status and apply a pulse oximeter
D. Attach electrodes to monitor cardiac rhythm
C. Determine respiratory status and apply a pulse oximeter
The nurse is administering multiple medications to a 78-year-old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make?

A. Cumulative serum drug levels and toxicity
B. Synergistic actions due to simultaneous administration
C. Tolerance to drugs that have been taken for long periods of time
D. Antagonist actions of multiple medications
A. Cumulative serum drug levels and toxicity
In obtaining an orthostatic vital sign measurement, what action should the nurse take first?

A. Count the client's radial pulse
B. Apply a blood pressure cuff
C. Instruct the client to lie supine
D. Assist the client to stand upright
C. Instruct the client to lie supine
A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period?

A. Diaper weights and urin specific gravity
B. Gastronomy feedings in supine position
C. Nipple feedings with glucose water
D. Gavage feedings with 15mL of formula
C. Nipple feedings with glucose water
Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the nurse. After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a Semi-Fowler's position. However, the nurse meets resistance and the clients voicees discomfort. What action should the nurse take next?

A. Attempt to withdraw additional fluid from the balloon
B. Assist the client in taking a series of deep breaths
C. Lower the head of the client's bed so the client is supine
D. Allow the client to rest before continuing to remove the catheter
B. Assist the client in taking a series of deep breaths
The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throws it across the room and curses loudly. What action should the nurse implement?

A. Transfer the medications to another bottle that is easier to open
B. Leave the client's home immediately and plan to return later
C. Igonore the outburst and demonstrate how to open the bottle
D. Describe other types of medication containers that are available
D. Describe other types of medication containers that are available
At 7AM, a Diabetic client is conscious with a serum glucose level of 50mg/dL. To manage this client's care effectively, what should the nurse administer?

A. Orange juice
B. Glucagon
C. 10 units of regular insulin
d. IV of 5% glucose in water at 100 mL/hr
A. Orange juice
A nurse is caring for a client with Multiple Sclerosis (MS) who is receiving an immunsupressant. Which action is most important for the nurse to implement to evaluate for adverse effects from this particular medication?

A. Observe the client's skin for bruising
B. Auscultate the client's bowel sounds
C. Monitor the clients intake and output
D. Note changes in the client's weight
D. Note changes in the client's weight
A male client with Hypercholesterolemia is being discharged with a new prescription for simvastatin (Zocor). The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond?

A. Instruct the client that the only regular testing needed is to monitor his cholesterol level
B. Teach the client that liver test are usually only done if the client reports symptoms
C. Review with the client that renal function tests are needed, rather than liver tests
D. Confirm that the client correctly understands the need to monitor liver function regularly
D. Confirm that the client correctly understands the need to monitor liver function regularly
An obese female client with a high serum cholesterol level comes to the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the nurse to provide?

A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels
B. Discuss the importance of maintaining a target heart rate during each excercise period
C. Teach the client additional ways to lower cholesterol, including stress management
D. Praise the client for her excercise and dieting efforts and encourage her to continue with this program
A. Explain to the lcient that her diet choice is not helpful in lowering cholesterol levels
A child with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage treatments?

A. Before postural drainage
B. During postural drainage
C. After postural drainage
D. Between treatements
C. After postural drainage
A client has a prescription for lorazepam (ativan) 1 mg for anxiety. The medication is supplied as 0.5mg tablets. How many tablets should the client take? (enter numeric value only.
2
The nurse is caring for a middle-aged client who had a Myocardial infarction (MI) 3 days ago. Which finding is most important for the nurse to report?

A. Frothy red-tinged sputum
B. Irregular heart rate
C. Two pound weight gain
D. Dependent edema
B. Irregular heart rate
A client is diagnosed with Clostridium Difficile (CDIFF). What action should the nurse implement to prevent the spread of the organism?

A. Place a surgical mask on the client during transport
B. Don non-sterile gloves when performing direct care
C. Wear a particular respirator mask when in the room
D. Keep the door closed to the client's room at all times
B. Don non-sterile gloves when performing direct care
A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly women.

A. Urinary retention resulting in renal calculi formation
B. Failing eyesight resulting in an unsafe environment
C. Osteoporosis resulting from hormonal changes
D. Transient ischemic attacks (TIAs) which impair mental activity
C. Osteoporosis resulting from hormonal changes
An elderly client is admitted for evaluation of Alzheimer's disease. At 2AM, the nurse finds the client tyring to open the emergency door. What is the most appropriate response for the nurse to make in this situation?

A. "This is the emergency door. Are you looking for the bathroom?"
B. "You look confused. Would you like to talk about your feelings?"
C. "Let's go back to your room. Your doctor does not want you to be walking alone."
D. "You want to go outside at this time of night? It's dangerous out there."
A. "This is the emergency door. Are you looking for the bathroom?"
Which nurse's behavior is a breach of client confidentiality according to the Health Insurance Portable Accountability Act (HIPPA) regulations?

A. A daily report sheet with the information of the team's clients is taken home.
B. Privileged health information (PH) is mailed through the US postal service
C. A client is called by both the first and last name in a public waiting room.
D. The ambulance health care provider is given information about the client's history
A. A daily report sheet with the information of the team's clients is taken home.
A client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the nurse to include in this client's record?

A. Pedal pulses, pallor, pain, paresthesia or paralysis
B. Level of consciousness, lung sounds, and bladder tone
C. Swallow reflex, nausea, and vomiting and IV infusion rate
D. Call bell side rails, bed in position, and ambulation aids
A. Pedal pulses, pallor, pain, paresthesia or paralysis
The nurse is standing at the clinic desk when a mother and preschool child approach. The mother tells the nurse that her child has a fever and rash. What action should the nurse take?

A. Take the child immediately to a different part of the clinic
B. Have them wait in the waiting area away from the other children
C. Tell the mother to return to the clinic when the rash subsides
D. Place them first on the list to see the healthcare practitioner
B. Have them wait in the waiting area away from the other children
A nurse is contributing to a care plan for an adolescent female client with Anorexia Nervosa. Which outcome statement or goal would be most appropriate for this client?

A She will participate in a daily aerobic exercise program
B. She will consume at least 50 percent of all meals
C. Her laboratory values will remain within normal limits
D. She will develop a positive body image and self-identity
D. She will develop a positive body image and self-identity
A female client with no family history of Breast Cancer (BA) asks the nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question?

A. Current age
B. Breast size
C. Breastfeeding history
D. Menopausal status
C. Breastfeeding history
The nurse is working on the postpartum unit and is assisting a new mother with her newborn's diaper change. The mother states that the infant fed well and completed the whole bottle of formula. What action should the nurse implement first when the infant begins to spit up during the diaper change?

A. Bubble or burp the infant by patting the infant's back
B. Encourage the mother to avoid over feeding the infant
C. Turn the newborn and bulb suction the mouth and nose
D. Wipe away the secretions and finish the diaper change
C. Turn the newborn and bulb suction the mouth and nose
An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond?

A. Review the importance of hygienic measures for improved health
B. State that the healthcare provider has prescribed a bath today
C. Offer the client several choices of times to bathe during the day
D. Request that the client clarify his religious beliefs about bathing
D. Request that the client clarify his religious beliefs about bathing
A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide?

A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits
B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina
C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn
D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection
D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection
The scope of practice for the practical nurse includes which client assessments?

A. An agitated client with bilateral wrist restraints
B. New admission of a client with deep vein thrombosis
C. Return of a postaneshesia client following a colon resection
D. Transfer of a client with sepsis from a long-term care facility
D. Transfer of a client with sepsis from a long-term care facility
What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day?

A. Cleanse the radiated area with water and pat the skin dry
B. Lightly massage the radiated skin with a lanolin-based lotion
C. Rinse the site with normal saline and cover with a sterile towel
D. Use of soft washcloth to gently remove the skin markings
A. Cleanse the radiated area with water and pat the skin dry
Which organ lays retroperitoeally?

A. Kidneys
B. Testicles
C. Urinary bladder
D. Pancreas
A. Kidneys
The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical excercises with the physical therapy department?

A. Before bedtime, at 2000
B. After breakfast
C. Before the evening meal
D. After lunch
B. After breakfast
The nurse is planning to ambulate client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first?

A. Place non-skid shoes on the client
B. Show the client how to use the call light
C. Use a gait belt to support the client
D. Assist the client to a bedside sitting position
D. Assist the client to a bedside sitting position
A Client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?

A. The neck extended backward using a rolled towel behind the neck
B. Prone position using pillows to support both arms outward from the torso
C. Side-lying position using pillows to support the abdomen and back
D. The neck forward using pillows under the head and sandbags on both sides
A. The neck extended backward using a rolled towel behind the neck
A client receives a new prescription for the angiotensin II receptor antagonist losartan (Cozaar). Which client instruction should the nurse encourage this client to follow?

A. Move slowly when getting up to prevent sudden dizziness
B. Take this medication with or after meals
C. Do not stop this medication until all of the tablets are gone
D. Keep the dietary log during initial therapy
A. Move slowly when getting up to prevent sudden dizziness
The healthcare provider prescribes erythromycin (ilosone) 300 mg PO QID. The medication label reads, "ilosone 100mg/5mL" How many mL should the nurse administer at each does? (Enter the numeric value only)
15
The nurse is monitoring a client with an IV infusion in the left antecubital fossae. The infusion pump is functioning without alarms at the prescribed rate of 100mL/hour. The site is warm, red and without swelling. What conclusion should these findings indicate to the nurse?

A. The IV fluids are infusing into the subcutaneous tissues and the pump should be stopped
B. The infusion pump is functioning properly and the IV site is healthy
C. The insertion date should be verified and the IV discontinued
D. The site is inflamed and should be reported to the RN for placement in another site.
D. The site is inflamed and should be reported to the RN for placement in another site.
The nurse reviewes the laboratory results of a client whose serum pH is 7.38 on the pH scale what does this value imply about the clients homeostasis

A. Alkalosis
B. Acidosis
C. Normal serum PH
D. Incompatible with life
C. Normal serum PH
The nurse plans to assess a newborn and to check the infant's Moro reflex. In assessing this reflex, the nurse is evaluating which parameter?

A. Neurological integrity
B. Renal functioning
C. Thermogenic regulation
D. Respiratory adequacy
A. Neurological integrity
The nurse assigns an unliscensed assistive personnel (UAP) to feed a client who is at risk for aspirations. To ensure that the task is safely delegated what action should the nurse implement?

A. Inform the UAP that the suction is available at the bedside
B. Instruct the UAP to notify the PN if the client begins to choke
C. Observe the UAP's ability to implement precautions during feed
D. Ask the UAP about previous experience performing this skil
C. Observe the UAP's ability to implement precautions during feed
The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?

A. Ask the client why the bath was refused
B. Ask family members to encourage the client to bathe
C. Explain the importance of good hygiene to the client
D. Reschedule the bath for the following day
A. Ask the client why the bath was refused
An adult female client is admitted to the psychiatric unit with diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?

A. Tell the client to keep her belongings because she will need them at discharge
B. Ask the client if she has had any recent thoughts of harming herself
C. Reassure the client that the antidepressant drugs are apparently effective
D. Support the client by telling her what wonderful progress she is making.
B. Ask the client if she has had any recent thoughts of harming herself
In assisting a client perform pursed lip breathing, the nurse should ensure that the client performs which action?

A. Inhale through the nose with the mouth shut and exhale through pursed lips
B. Inhale through pursed lips then exhale with the mouth held open
C. Inhale through pursed lips and then exhale through the nose with the mouth closed
D. Inhale through the mouth puff the cheeks and exhale through pursed lips
B. Ask the client if she has had any recent thoughts of harming herself
A 3 year-old admitted with fever of unknown origin (FUO) has begun vomiting in the past half hour. The child's temperature is 101.80 F, and the last dose of antipyretic medication was given 5 hours ago. The child has prescriptions of acetaminophen (Tylenol) 160 MG per 5 mL elixir or 160 mg suppositories PRN fever or pain. What action should the nurse take at this time?

A. Make the child NPO and hold all medications untill the vomiting has stopped
B. Give acetaminophen elixir to ensure the child's cooperation with swallowing
C. Notify the healthcare provider that the child's fever has become dangerously high
D. Use an acetaminophen suppository for the fever since the child is vomiting
A. Make the child NPO and hold all medications untill the vomiting has stopped
A client is having Radical Masectormy. What is the position of choice during the immediate postoperative period?

A. Side-lying on the operative side with the bed flat
B. Supine with the arm on the operative side in a dependant position
C. Semi-Fowler's position with the arm on the operative side elevated
D. Sim's position with the arm on the operative side in a dependant position
C. Semi-Fowler's position with the arm on the operative side elevated
The nurse assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepear for which treatment?

A. Heat lamp three times per day
B. Insertion of vaginal packing
C. Cold packs to the perineum
D. Operative excission of the hematomas
C. Cold packs to the perineum
A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer?

A. 0.025
B. 0.0025
C. 0.25
D. 25.0
C. 0.25
A school-aged child with AIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action?

A. Obtain penicillin G 1000U weekly
B. Obtain the varicella vaccine
C. Enroll in a home school program
D. Obtain the varicella zoster immune globulin
D. Obtain the varicella zoster immune globulin
The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client?

A. Nurse who contracts child protective services to report a mother's decision to refuse vaccination for her firstborn infant
B. Nurse refusing to care for a convicted rapist stating that personal discomfort would inhibit provision of quality of care
C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds
D. Nurse sharing information about life after death with a grievin family who just lost a loved one
C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds
The nurse is preparing a client for an Intravenous Pyelogram (IVP) scheduled for the following morning. What action is most important for the nurse to implement?

A. Determine if the client has any allergies to shellfish
B. Inform client that an IV dye will be administered before the IVP
C. Explain that dizziness may occur when the dye is given
D. Administer a bowel prep the evening before the procedure
A. Determine if the client has any allergies to shellfish
A nurse refuses to perform a procedure because itis beyond the scope of practice for practical nurses. Which resource best defines the nurse's legal responsibility in regard to scope of practice?

A. Nursing practice standards for Licensed Practical/Vocational Nurses
B. State Nurse Practice Act
C. Code of Ethics for Licensed Practical/Vocational Nurses
D. Patients Bill of Rights
B. State nurse Practice Act
While making the bed of a female client who is sitting in the bedside chair, the nurse observes the client seem anxious. To encourage verbalization by the client, what action should the nurse take?

A. Continue to make the bed while conversing with the client
B. Sit next to the client at a slight angle to continue the conversation
C. Remain standing close enough to the client to hold her hand
D. Bring a chair face-to-face with the client for further discussion
B. Sit next to the client at a slight angle to continue the conversation
A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA). The nurse anticipates implementing care for which client problem?

A. High risk for injury
B. Altered breathing patters
C. Ineffective airway clearance
D. High risk infection
B. Altered breathing patters
An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client?

A. The physical therapis will instruct the client in the use of a walker
B. The nurse will place a gait belt on the client prior to ambulation
C. The client will ambulate with assistance q4h
D. The client will use self-affirmation statements to decrease fear
C. The client will ambulate with assistance q4h
A female client complains to the nurse about being admitted to a semi-private room and expresses her displeasure because she requested a private room prior to admission. What response is best for the nurse to provide this client?

A. Room assignments are based on client's acuity level, not necessarily by request
B. I will place your name on the room request list for the next available private room
C. Your healthcare provider must provide a written request to get you a private room
D. There are no private rooms available, so you will have to stay here for the time being.
C. Your healthcare provider must provide a written request to get you a private room
During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery?

A. "Deep breathing exercises using spirometer will help prevent postoperative complications."
B. "failure to keep your lungs working may result in pneumonia and death."
C. "Incentive spirometry is uncomfortable but necessary for your postoperative care."
D. "You will use the spirometer for the first postoperative day only."
A. "Deep breathing exercises using spirometer will help prevent postoperative complications."
The nurse is caring for a client who had a total Laryngectomy, Left Radical Neck Dissection, and tracheostomy. The client is receiving Nasogastric (NG) tube feedings via an enteral pump. Today the rate of the feeding was increased from 50mL/hr to 75mL/hr. What parameter should the nurse evaluate the client's tolerance to the rate of feeding?

A. Bowel sounds
B. Urinary and stool outputs
C. Gastric residual volumes
D. Daily weight
C. Gastric residual volumes
A client is admitted with a fever of undermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first?

A. Change the bed linen to prevent chilling
B. Check the client's vital signs and pain scale
C. Assess the client for urinary incontinence
D. Determine fluid intake for the past 8 hours
B. Check the client's vital signs and pain scale
Which client should the nurse assign to an unlicensed assistive personnel (UAP)?

A. An older male client with melena who is complaining of abdominal pain and needs a guaic test of a stool sample
B. A young adult experiencing flank pain and hematuria who needs all urine strained for stones
C. A client who has regular heart rate and after a pacemaker replacement now needs to ambulate
D. An elderly client with Right-Sided Hemiplegia and Receptive Aphasia who needs to be transfered to the wheelchair
C. A client who has regular heart rate and after a pacemaker replacement now needs to ambulate
The nurse is administering the shingles vaccine to an older male-client who asks why he should receive the immunization. Which information should the nurse provide?

A. A history of chickenpox indicates that the harbors the dormant virus
B. The client's last dose of adult immunizations was 10 years ago
C. A recent outbreak of fever blisters indicates reactivation of the virus
D. Multiple stressful personal experiences increase his risk of shingles
A. A history of chickenpox indicates that the harbors the dormant virus
In preparing a client for a lumbar puncture, what action should the nurse implement?

A. Assist the client to the bathroom to void
B. Apply a pulse oximeter to the client's finger
C. Teach the client to cough and deep breathing exercises
D. Ensure that the client has been NPO for six hours.
C. Teach the client to cough and deep breathing exercises
A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation?

A. Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations
B. Change the Pleur-Evac system and re-assess output in the empty chamber
C. An increase in the prescribed suction force to facilitate-drainage of serosanguineous fluids
D. Advance the chest tube to ensure proper placement of the tip to enhance drainage
B. Change the Pleur-Evac system and re-assess output in the empty chamber
While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fuity odor. What assessment should the nurse perform first?

A. Auscultate the client's bowel sounds
B. Determine the client's capillary glucose
C. Observe the color of the client's urine
D. Measure the client's oxygen saturation
B. Determine the client's capillary glucose
The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client?

A. Upper torso
B. Head
C. Feet
D. Upper extremities
A. Upper torso
A 60 year-old client with cancer of the liver is in Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one?

A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours"
B. "The nurses have not been able to arouse the client and the healthcare provider knows the outcome."
C. "You need to discuss the condition with the charge nurse in a family conference."
D. "The client's condition is extremely critical. Has your family made funeral arrangements?"
A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours"
A client complains of kidney pain. The nurse understands that the kidneys are located where?

A. On the retroperitoneal posterior abdominal wall at the costovertebral angle
B. Within the curve of the duodenum, posterior to the spleen
C. Lateral to the stomach in the hypochondriac region
D. Superior aspect of the bladder in right and left iliac region
A. On the retroperitoneal posterior abdominal wall at the costovertebral angle
The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site?

A. Umbilical area of the abdomen
B. Antecubital fossae of the arm
C. Chest wall below the clavicle
D. Dorsal surface of the hand
C. Chest wall below the clavicle
The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number)

75mL X 15gtt/mL = 38
38
The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD?

A. Anemia
B. Anuria
C. Hypotension
D. Edema
A. Anemia
The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action?

A. Confirm the room and bed numbers with those on the medication record
B. Ask a regular staff member to confirm the residents identity
C. Hold the medication untill a family member arrives
D. Re-orient the resident to name, place and situation.
B. Ask a regular staff member to confirm the residents identity
The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit?

A. Edemetous lower extremities and an increased temperature
B. A decreased temperature and increased blood pressure
C. Dry skin and an increased heart rate
D. Diaphoresis and hypertension
C. Dry skin and an increased heart rate
An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that this client is exhibiting which signs or symptom?

A. Delusions of persecution
B. Ideas of reference
C. Hallucinations
D. Confabulation
A. Delusions of persecution
The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is "gurgling" on oral secretions and coughing. Which action should the nurse take first?

A. Position the client supine
B. Finger sweep the oral cavity
C. Perform oral suctioning
D. Provide mouth care
C. Perform oral suctioning
What length of blood pressure cuff should be the nurse use when obtaining a client's blood pressure?

A. A cuff that is no longer than the circumference of the extremity should be used
B. The lenght of the blood pressure cuff does not make a difference
C. The cuff and its bladder should be nearly encircled the the extremity's circumference
D. At least two-thirs the circumference of the extremity should be coverered
C. The cuff and its bladder should be nearly encircled the the extremity's circumference
A nurse is assisting a client from the bathroom back to bed following a minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take?

A. Place a cool rag on the client's head
B. Suction the client's oral cavity
C. Provide the client an emesis basin
D. Place the client in a side-laying position
D. Place the client in a side-laying position
The nurse is caring for a 10-year-old child with hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurst take when interacting with the child and mother?

A. No special precautions are needed
B. Wear gloves only
C. Wear gloves and a mask
D. Wear a mask, gloves and gown.
A. No special precautions are needed
A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client?

A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped
B. They should wait to resume sexual activities until the fatigue assorted with a new baby has passed
C. They can resume sexual activity at 6 weeks postpartum
D. It is best to wait until both parties feel up to having sexual intercourse
A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped
The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news?

A. Refer the family to a support group to find answers to their questions
B. Reinforce the stages of the grieving process
C. Listen to the family's reactions and reflect and their fears and concerns
D. Transfer the child to a private room
C. Listen to the family's reactions and reflect and their fears and concerns
The nurse is implementing the plan of care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

A. Describes being very depressed
B. Has little appetite and neglects personal hygiene
C. Is not interested in the activities of family and friends
D. Begins to show signs of improvement
D. Begins to show signs of improvement
On a short-staffed unit a long-term care facility, it is important that the nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first?

A. Dyspnea who uses oxygen continously
B. Straight catheterization to be performed q6h
C. Frequent episidoes of fecal incontinence
D. Bolus feeding via PEG tube to be performed q4h
C. Frequent episidoes of fecal incontinence
The nurse assess a client receiving a hypertonic full strength tube feeding that is infusing continous at 50 mL/hr. Which finding is most important for the nurse to reprot to the charge nurse?

A. Dry mucous membranes
B. Gastric residual of 50 mL
C. Report of increased hunger
D. Hyperactive bowel sounds
C. Report of increased hunger
A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next?

A. Explain the consequences of Sepsis if the amputation is delayed
B. Notify the RN that the client's wife needs further explanation about the procedure
C. Document on the client's record the refusal for surgical treatment
D. Enourage the client's wife to express concerns about making the decision
D. Enourage the client's wife to express concerns about making the decision
A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choise are cocaine and heroin. What is the greatest health risk for this client?

A. Hepatitis
B. Hypertention
C. Diabetes
D. Glaucoma
D. Glaucoma
A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next?

A. Explain the consequences of Sepsis if the amputation is delayed
B. Notify the RN that the client's wife needs further explanation about the procedure
C. Document on the client record the refusal for surgical treatement
D. Encourage the client's wife to express concerns about making the decision
D. Encourage the client's wife to express concerns about making the decision
The nurse is caring for a group of clients on a postpartum unit. After shift report, which client should the nurse assess first?

A. Gravida 6 Para 5 who delivered vaginally 24 hours ago
B. Gravida 1 Para 0 who is not having contractions
C. Gravida 3 Para 3 who delivereed vaginally 2 hours ago
D. Gravide 1 Para 2 who is preparing for dischage
C. Gravida 3 Para 3 who delivereed vaginally 2 hours ago
A client returns to the unit following a cardiac catheterization with a Femoral artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return?

A. Pupil responses to light
B. Pedal pulses
C. Respiratory rate
D. Peripheral mobility
B. Pedal pulses
An elderly female client tells the nurse that she does not do regular Breast Self Examinations (BSE) because she is too old. The nurse's response to the client is based on what information?

A. The incidence of breast cancer increases with age
B. The client should have a health care provider do a breast exam at least once a year
C. After age 70, breast cancer is less likely to occur
D. The history of breast cancer in a family member is indicative of the need for BSE
A. The incidence of breast cancer increases with age
A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what interventions should the nurse implement?

A. Maintain an oral airway suction equpment and oxygen at the bedside
B. Provide respiratory isolation precautions for visitors and staff
C. Provide emergency anti convulsant medication at the bedside
D. Maintain a quiet calm darkened enviornment
D. Maintain a quiet calm darkened enviornment
The nurse is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next?

A. Initiate the urine stream
B. Seperate the labia
C. Position the collection cup
D. Observe the urine
B. Seperate the labia
A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should action should the nurse take?

A. Report the UAP's omission to the charge nurse
B. Complete an unusual occurence report
C. Supervise the UAP after reviewing the protocol
D. Assign the UAP to more stable clients the next day
C. Supervise the UAP after reviewing the protocol
What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling catheter (Foley)?

A. Keep the catheter intact while assisting the client with a shower
B. Remove the catheter while the client takes a shower
C. Provide the client with a sponge bath in a chair or the bed
D. Assist the client with a tub with the catheter clamped
A. Keep the catheter intact while assisting the client with a shower
Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary incontinence?

A. Maintain standard precautions
B. Utilize an antibacterial perineal wash
C. Insert an indwelling urinary catheter
D. Initiate contact isolation precautions
A. Maintain standard precautions
The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first?

A. Ask the client if she has previously been catheterized
B. Position the client and observe the urinary meatus
C. Obtain a 30 ml syringe and a vial of sterile water
D. Consult with the chage nurse about the catheter
D. Consult with the chage nurse about the catheter
An 82-year old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to...

A. Prevent foot drop
B. Prevent hip dislocation
C. Promote moving in bed
D. Promote early ambulation
A. Prevent foot drop
Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately?

A. My left foot is so painful
B. My incision is so dry
C. I've been feeling so light headed
D. I'm tired of turning so much
C. I've been feeling so light headed
In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client?

A. Empty and measure the drainage in the suction drainage device
B. Reassure the client that phantom limb pain is genuine pain
C. Review the client's vital signs for indications of infection
D. Observe and mark the amount of drainage on the dressing
A. Empty and measure the drainage in the suction drainage device
2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limites and her sugar is 325 mg/dL. what intervention should the nurse implement first?

A. Give the client 4 ounces of orange juice
B. Administer next scheduled dose of metformin (Glucophage)
C. Cancel the clients dinner tray
D. Administer regular insulin per sliding scale
D. Administer regular insulin per sliding scale
A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression devise (SCD) to both lower extremities. (BLE). What action is important when turning the client to a lateral position?

A. Decrease the amount of pressure exerted on both legs while turning the client
B. Replace the SCD's with an antiembolic stockings while using an abduction pillow
C. Remove both of the SCDs while the cient is turned to the lateral position
D. Observe the SCDs continue to inflate and deflate when the client is turned
D. Observe the SCDs continue to inflate and deflate when the client is turned
When the nurse asks a male client with Bipolar Disorder if he is going to group session, he responds, "there is no use in me going to that group because all they talk about is Schizophrenia, which doesn't apply to me." Which response is best for the nurse to provide this client?

A. "Tell me what medications you are taking right now"
B. "You are probably right. The group really does not apply to your condition."
C. "It sounds to me like it may be better for you that you stay here"
D. "Let's talk about what you may have in common with the other group members."
D. "Let's talk about what you may have in common with the other group members."
A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of tuberculosis (TB)?

A. Proper disposal of tissues when coughing
B. Importance of an adequate diet
C. Complication sof the disease
D. Side effects of anti-tubercular medications
A. Proper disposal of tissues when coughing
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not rising. What action should the nurse take first?

A. Reposition the head to ensure an open airway
B. Inflate the lungs with more breaths and air pressure
C. Finger sweet for a foreign body lodged in the oral cavity
D. Reposition hands on chest continue compressions
A. Reposition the head to ensure an open airway
After a change of shift report, the nurse makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the nurse?

A. A client who is having bright red drainage from the rectum following a colonoscopy with a polyp removal
B. A client who has pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy
C. An older client whose blood pressure is 100/70 after receiving meperidine for pain related to a hip fracture
D. A client who has brown green bile draining froma T-tube after a cholecystectomy for Cholelithiasis.
A. A client who is having bright red drainage from the rectum following a colonoscopy with a polyp removal
Augmentin (amoxicillin/clavulante) 500mg suspension is prescribed for an older adult client who has trouble swallowing . The suspension is available in 125mg/5mL solution. How many ml should the client receive? (enter the numberic value only)

500mg/125m X 5mL = 20mL
20
The nurse observes that there are secretions in the air vent lumen of client's double lumen Nasogastric tube (NGT). Which action should the nurse implement?

A. Instill 20 mL of air into the second lumen
B. Irrigate the primary lumen with 20 mL of saline
C. Place the client in a high Fowler's position
D. Turn the suction device to continous suction
A. Instill 20 mL of air into the second lumen
Which pediatric client is most likely to experience a disturbed body image?

A. 10-year-old with plantar warts
B. 14-year-old with acne vulgaris
C. 16-year-old with a perineal tinea infection
D. 12-year-old with bacterial cellulitis
B. 14-year-old with acne vulgaris
The first day after a cesarean section (C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take?

A. Insert an indwelling catheter to empty the bladder and contract the fundus
B. Return the client to bed and maitain bed rest until the lochial flow slows
C. Check fundal consistency and continue to monitor the lochial flow amount
D. Massage the fundus and avoid direct pressure on the cesarean incision.
C. Check fundal consistency and continue to monitor the lochial flow amount
The nurse is emptying the bedpan of a client with a bleeding gastric ulcer. What type of stool can the nurse expect this client to have.

A. Black tarry stool
B. Coffee-ground stool
C. Bright red bloody stool
D. Clay-colored stool
A. Black tarry stool
Which structure of the tracheobronchial tree is the most likely to compromise air passage when the smooth muscle layer is affected?

A. Secondary bronchi
B. Bronchioles
C. Segmental bronchi
D. Alveolar ducsts
B. Bronchioles
The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging, increases the elderly client's risk of having an adverse response to the medication?

A. Decreased gastrointestinal motility
B. Poor cognitive function
C. Poor peripheral circulation
D. Decreased mobility
A. Decreased gastrointestinal motility
A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the
left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first?
A. Bathe the wound daily with soap and water
B. Record the color and temperature of the leg
C. Perform dorsal flexion and extension exercises
D. Check the client's dorsalis pedis and posterior tibialis pulse point
D. Check the client's dorsalis pedis and posterior tibialis pulse point
An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first
time. What is the best intervention for the nurse to implement?
A. Clamp the catheter and assist the client with a tub bath
B. Keep the catheter intact and assist the client with a shower
C. Encourage the client to do self-care and provide personal care products
D. Assist the client with a sponge bath in a chair or the bed
B. Keep the catheter intact and assist the client with a shower
The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff
member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer.
What is the best Nursing action?

A. Approach the individuals involved and ask them to stop
B. Write an incident report and submit it to the unit manager
C. Tell the client of the UAPs concern for him
D. Try not to listen to the conversation since it is confidential
B. Write an incident report and submit it to the unit manager
During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending
increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which
action should the nurse take?
A. Withhold any medications that may cause these side effects
B. Motivate the client by offering favorite foods as a prize
C. Ask the family members to visit more often to stimulate the client
D. Record the findings and report the symptoms to the charge nurse
D. Record the findings and report the symptoms to the charge nurse
A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the
client to manifest in response to the administration of this drug during an acute anginal episode?

A. Pulse oximetry within normal limits
B. Cessation of acute chest pain
C. Hypertension and headache
D. Premature ventricular contractions (PVC)
B. Cessation of acute chest pain
After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-pound
weight loss from the pre-dialysis weight. The client reports feeling weak and fatigued. What action should
the nurse take next?

A. Measure the client's blood pressure
B. Auscultate the client's breath sounds
C. Observe the client's legs for edema
D. Determine the client's blood glucose
A. Measure the client's blood pressure
When providing oral care to an unconscious client who is a mouth breather and does not swallow, which
action is most important for the nurse to implement?

A. Use an oral suction catheter in the buccal cavity
B. Inspect the oral cavity using gloves fingers
C. Perform oral cleansing with a sponge toothette
D. Apply a petroleum based lubricant to the client's lips
A. Use an oral suction catheter in the buccal cavity
Wrist restrains were applied to a client who was severely agitated and disoriented. In monitoring the
client, who is now asleep, which finding should be reported to the charge nurse?

A. Respiratory rate decreases from 22 to 16 per minute
B. Radial pulse volume decreases from +3 to +1
C. Blood pressure decreases from 130/84 to 120/76
D. Apical pulse rate decreases from 94-84 per minute
B. Radial pulse volume decreases from +3 to +1
The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the
goal, "An increase in granulation tissue will develop within 2 weeks," which intervention should the nurse
implement?

A. Remove heel protector every two hours
B. Irrigate wound with sterile normal saline
C. Replace dry sterile dressings as needed
D. Apply heat for 15 minutes three times daily
B. Irrigate wound with sterile normal saline
A client's chief complaint is being able to swallow only small bites of solid food and liquid's for the last 3
months. The nurse should assess the client for what additional information?

A. History of alcohol and tobacco use
B. Average daily consumption of hot beverages
C. Past traumatic injury to the neck
D. Daily dietary roughage intake
A. History of alcohol and tobacco use
The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional
conflict related to concerns about mechanical ventilation." When assigned to care for this client, what
intervention should the nurse implement based on this diagnosis ?

A. Provide an opportunity for the client to meet with survivors of the disease who have undergone mechanical
ventilation
B. Remind the client that a mechanical ventilator is usually only needed for a short period of time
C. Ask the hospice nurse to visit with the client to discuss his options for care if he chooses not to undergo
mechanical ventilation
D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation
D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation
What is the function of neutrophils?

A. Heparin secretion
B. Transport oxygen
C. Phagocytotic action
D. Antibody formation
C. Phagocytotic action
Which membrane lines the abdominal cavity?

A. Perineum
B. Pericardium
C. Pleura
D. Peritoneum
D. Peritoneum
A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling
on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take?

A. Tell the man when the elevator will see him
B. Alert the staff to monitor exits to prevent escape
C. Warn the client that he is likely to have a seizure
D. Offer a hot meal a clean bed and a sleeping pill
D. Offer a hot meal a clean bed and a sleeping pill
The nurse is assessing care for residents on a 12-bed unit in an extended care facility. The staff consists of 1
unlicensed assistive personnel (UAP) and 1 certified medication aide. Which task should the nurse perform?
A. Ambulate the client who has left hemiplegia and uses a cane
B. Administer medications and formula to a client with a gastronomy tube
C. Change a hydrocolloid dressing for a client with a stage II pressure ulcer
D. Provide self-catheterization equipment for a client with paraplegia
B. Administer medications and formula to a client with a gastronomy tube
The nurse is reviewing the discharge medication instructions with a client for disulfiram 10mg (Antabuse).
Which instruction should the PN reinforce with the client?

A. Avoid all sources of alcohol while taking this drug including cough syrups
B. The medication should be taken at the same time each day
C. Stop the drug if nausea, vomiting and/or prostration occur
D. Have weekly blood tests to determine therapeutic drug levels and serum sodium
A. Avoid all sources of alcohol while taking this drug including cough syrups
The nurse is preparing a client for a bone marrow aspiration. Which erythropoietic site is most likely to be
used to obtain the specimen?
A. Vertebrae
B. Ribs
C. Cranial bones
D. Iliac crest
D. Iliac crest
A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water
during the night. What intervention will the nurse implement first?

A. Auscultate the client for bowel sounds and ability to urinate
B. Determine the amount of water and exact time it was taken
C. Notify the healthcare provider of the client's fluid intake
D. Reassure the client that a small amount of water is not harmful
B. Determine the amount of water and exact time it was taken
The nurse is providing care for a client receiving an intravenous antibiotic to treat an infection. Which
assessment findings require the most immediate action by the RN?

A. Warm skin with elastic turgor
B. Dry mouth with thirst
C. Low grade fever with diaphoresis
D. Hives with pruritus
D. Hives with pruritus
The nurse should perform oral suctioning for a client with what problem?

A. Atelactasis
B. Dysphasia
C. Gastric reflux
D. Dysphagia
D. Dysphagia
An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and
then tells the nurse, "I just don't feel right" Which initial action should the nurse take?

A. Assess temperature
B. Evaluate deep tendon reflexes
C. Give 4 ounces of apple juice
D. Administer glucagon 0.5mg IM
C. Give 4 ounces of apple juice
A 75-year-old male client with Alzheimer's Disease (AD) is admitted to an extended care facility. What
intervention should the nurse include into his client's Nursing care plan?

A. Describe the activities available to the residents and encourage him to choose the ones he prefers
B. Introduce the client to the Nursing staff and the residents as soon as possible
C. Plan to have the same Nursing staff provide care for the client whenever possible
D. Encourage the client to remain on the unit for 3 weeks until he is oriented to his new surroundings
C. Plan to have the same Nursing staff provide care for the client whenever possible
A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively.
What intervention should the nurse implement during the GT feedings?

A. Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings
B. Flush the GT with 50mL of water and clamp the GT to prevent leakage
C. Place the infant in the right lateral position to facilitate gastric emptying
D. Burp the infant after each 10mL of formula administration and re-feed any volume that is spit up
A. Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings
Which intervention is within the scope of practice for a nurse?

A. Demonstrating deep breathing and coughing to postoperative client
B. Teaching the use of glucometer to a newly diagnosed diabetic client
C. Presenting support options that are available to those with cancer
D. Discharge teaching about newly prescribed medications
A. Demonstrating deep breathing and coughing to postoperative client
The nurse is preparing a client for a mammogram. What instructions should the nurse provide the client?

A. Do not exercise the upper body on the day of the procedure
B. Avoid taking aspirin for one week prior to the procedure
C. Avoid eating or drinking 6 hours prior to the procedure
D. Do not use underarm deodorant on the day of the procedure
D. Do not use underarm deodorant on the day of the procedure
An older client is transferred to the rehabilitation unit with the diagnosis of Cerebrovascular Accident (CVA)
with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left leg
and states, "There is a leg in my bed!" What is the best response by the nurse?

A. "Your stroke has impaired your ability to recognize your paralyzed leg."
B. "Look at your legs and you will see that they both belong to you."
C. "Please explain to me what you thing happened to your leg."
D. "I know you think there is an extra leg in your bed, but I do not see it."
D. "I know you think there is an extra leg in your bed, but I do not see it."
Which technique should the nurse use to give a Z-track intramuscular injection?

A. Ensure that no air is present in the syringe
B. Inject the medication into the dorsal gluteal site
C. Select a 22-gauge, 1 inch needle for injection
D. Massage the site for 2 minutes after the injection
B. Inject the medication into the dorsal gluteal site
The nurse observe that the IV catheter is no longer in a client's arm. It is on the bed, and the sheets are
moist with IV fluid. The client is disoriented and states he does not remember pulling the catheter out. How
should the nurse document this situations?

A. Client does not remember pulling out the IV
B. IV catheter found lying on bed sheets
C. IV catheter pulled out by disoriented client
D. IV discontinued and wet sheets changed
B. IV catheter found lying on bed sheets
The nurse identifies several findings in an older female who is on prolonged bed rest. Which finding requires
prompt action by the nurse?

A. Heart rate increases of 10 beats per minute
B. Bowel movements decrease to 1 every third day
C. Urinary output decreases of 250mL in the last 24 hours
D. D. Systolic blood pressure decrease of 10mmHg
B. Bowel movements decrease to 1 every third day
A nurse sees a colleague taking drugs from the hospital unit. What action should the nurse take?

A. Report the incident to the person in charge of the unit or Nursing supervisor
B. Notify the hospital security staff to retrieve the drugs from the colleague
C. Report the colleague to the peer review committee of the hospital
D. Confront the colleague and tell him/her to take the drugs back to the unit
A. Report the incident to the person in charge of the unit or Nursing supervisor
Which term describes 2 or more tissues that compose a structure and perform a specific function?

A. Elastic tissue
B. Organ
C. System
D. Serous membrane
B. Organ
How many mL should the nurse document when calculating a client's 8-hour fluid intake? (Enter the numeric
value only.)
0730 - 4 ounces of orange juice, hardboiled egg, and toast
1130 - 1/2 cup of soup, one half sandwich, and 1/2 cup of apple juice
1300 - vomitus of 100 mL
1400 - voided 250 ml and consumed one 12-ounce can of soft drink
(type your answer in the box below)
1oz = 30mL; so 4oz of orange juice X 30mL = 120mL of orange juice
Then 1 cup = 240; so ½ cup is 120mL of soup and ½ cup of apple juice is 120mL of apple juice = 240mL total
vomitus is output, not intake, so ignore
voided is output, not intake, so ignore
1 oz = 30mL; so 12oz is 12oz X 30mL = 360mL
add them all; 120mL + 240mL + 360mL = 720mL
720
A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine. He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse
implement?

A. Offer the client a full glass of water
B. Give medications 2 hours apart
C. Provide a snack with the medications
D. Administer only the docusate sodium
A. Offer the client a full glass of water
The nurse is caring for a primagravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse?

A. Pulse rate of 90 beats/minute
B. Rubor lochia saturating 3 perineal pads per hour
C. Complaints of perineal pain
D. Firm fundus between umbilicus and the symphysis pubis
B. Rubor lochia saturating 3 perineal pads per hour
A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan?

A. Drink 3 quarts of water daily
B. Avoid swimming in public pools
C. Avoid intercourse until all antibiotics have been taken
D. Drink 3, 6-ounce cans of cranberry juice daily
A. Drink 3 quarts of water daily
Which criterion is best for the nurse to use when evaluating a client's response to an analgesic that was administered for postoperative pain?

A. Amount of medication required to relieve pain
B. Activity without guarding or grimacing
C. Objective parameters of blood pressure and respirations
D. Subjective score on a 1 to 10 pain scale
D. Subjective score on a 1 to 10 pain scale
A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer?

A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack
B. The space around your heart is filling with fluid and your healthcare provider will have to explain the
treatment
C. The heart cells have been infiltrated by organisms and a secondary autoimmune reaction has
occurred
D. This is an infection of the lining of the heart caused by bacteria entering through your gums
A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack
In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is...
A. a 40-year-old African American with Hypertension (HTN)
B. a 35-year-old with trauma to the breast
C. a 32-year-old whose mother had breast cancer
D. a 50-year-old Caucasian who has never had a mammogram
C. a 32-year-old whose mother had breast cancer
What technique should the nurse use to administer a medicated ophthalmic ointment?

A. Massage the lashes with the excess ointment that is squeezed out when shutting the lids
B. Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus
C. Pull both upper and lower lids apart to drop the ointment onto the anterior surface of the eye
D. Wear gloves when placing the tip of the ointment tube in the center of the lower lid
B. Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus
A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrghaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what
action?

A. Using a tight seal around the mouth piece
B. Exhaling slowly after two seconds
C. Blowing forcefully into the mouthpiece
D. Sitting upright during treatment
C. Blowing forcefully into the mouthpiece
An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast. Which cereal should the nurse provide?

A. Corn flakes
B. Granola
C. Oatmeal
D. Wheat puffs
E. Rice
E. Rice
The nurse assumes care of a client who was admitted earlier in the day for a scheduled Hysterectomy in the morning. Which recorded assessment data obtained by the admitting registered nurse is objective? (Select all that
apply).

A. Anemia
B. Menorrhagia
C. Tiredness
D. Orthostatic hypotension
E. Fear
F. Nervousness
205. The nurse empties
A. Anemia, D. Orthostatic hypotension
The nurse empties a large amount of serous drainage from a postoperative client 's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the
bottom.)
Compress drain... close drain... discard drain... document
Compress drain... close drain... discard drain... document
The nurse should recommend that males over the age of 45 obtain which test to screen for prostatic cancer?

A. Prostate-specific antigen (PSA)
B. Alpha-fetoprotein radio immunoassay (AFP)
C. Ultrasound of the scrotum
D. Serum testosterone level
A. Prostate-specific antigen (PSA)
The nurse is giving medications to a client who was admitted to the hospital with a diagnosis of Diabetes Mellitus Type II. After checking the finger stick glucose at 1630dL, what dose of insulin should the nurse administer? (enter the numeric value only) (Click on each chart tab for additional information. Please be sure to
scroll to the bottom-right corner of each tab to view all information contained in the client's medical
record.)
8
A client is receiving 0.5 grams of a prescription medication that is dispensed as 500 mg/5mL. How many ml should the PN administer? (enter the numeric value only. If rounding is required, round to the nearest
tenth.)
5
The nurse is receiving a client following an emergency Cesarean Section (C-Section). Which information is most important for the nurse to obtain?

A. Blood pressure and pulse rate
B. Gravida and parity
C. Medications received during labor
D. Temperature and respiratory rate
A. Blood pressure and pulse rate
The nurse is preparing to insert an indwelling catheter for an 89-year-old client who has severe contractures of both lower extremities. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. What action should the nurse take?

A. Report to the charge nurse that the client cannot cooperate for the insertion
B. Recruit two UAPs to hold the legs apart while the catheter is inserted
C. Position laterally for posterior access in visualizing the meatus for insertion
D. Pre-medicate the client with a narcotic analgesic to relax the skeletal muscles
C. Position laterally for posterior access in visualizing the meatus for insertion
An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath sounds frequently. What other intervention
should the nurse implement related to the client's decreased vital capacity?

A. Evaluate pulse oxygen saturation
B. Allow extra education time
C. Encourage high protein supplements
D. Monitor intake and output
A. Evaluate pulse oxygen saturation
The nurse can also refer to the external ear as what other known name...

A. Pinna
B. Malleus
C. Incus
D. Cochlea
A. Pinna
During immediate postoperative period, which condition has the highest priority when planning Nursing care?

A. Infection
B. Respiratory obstruction
C. Dehydration
D. Cardiac arrest
B. Respiratory obstruction
The nurse is providing instructions to the unlicensed assistive personnel (UAP) preparing to instruction is most important for the nurse to emphasize?

A. Keep the head of the bed raised while the tube feeding is infusing
B. Report any drainage observed around the GT insertion site
C. Raise the entire bed while bathing the client to reduce back strain
D. Use plenty of pillows to position the client on the side after bathing
B. Report any drainage observed around the GT insertion site
A client is admitted to the rehabilitation unit after a Thrombotic Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive aphasia. What intervention should the nurse implement to communicate with the
client?

A. Picture communication board
B. Request a family member to interpret
C. Electronic larynx device
D. Dysphagia precautions
D. Dysphagia precautions
The nurse is reviewing instructions for the use of pilocarpine eye drops with a client who has Glaucoma. The client states, "I should have these drops to anesthetize my eye if I experience pain" What action should the nurse implement?

A. Explain to the client the eye drops do provide pain relief, but do not anesthetize the eyes
B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not
common
C. Re-teach the client about the action of the eye drops to decrease pressure in the eye
D. Document in the chart that the client understands the action and use the eye drops
C. Re-teach the client about the action of the eye drops to decrease pressure in the eye
A client is complaining of muscle fatigue in the lower extremities. What is the physiological cause of muscle fatigue?

A. The depletion of glycogen and energy stores
B. Electrical stimulus failure at the neuromuscular junction
C. Calcium concentration decrease in the muscle sarcomere
D. Hyperoxygenation of the muscle fiber
A. The depletion of glycogen and energy stores
A client asks the nurse to explain the location of the prostate gland. What is the best response?

A. Close the rectal wall the prostate gland sits behind the symphysis pubis extending around the
beginning of the urethra
B. At the bottom of the scrotal sac, the prostate gland rests beneath the testes, held in place by the
spermatic fascia
C. Attach to the front and sides of the pubic arch, the prostate is a mess of cavernous tissue held
together by fibrous tissue
D. Located at the lateral edge of the posterior segment of the testes, the prostate creates a bulge
continuous with the vas deferens
A. Close the rectal wall the prostate gland sits behind the symphysis pubis extending around the
beginning of the urethra
A female client is being prepared for a speculum exam. In which position should the nurse place the client?

A. Left Sims
B. Semi-Fowler's
C. Lithotomy
D. Trendelenburg
C. Lithotomy
The nurse is caring for an elderly client who has suddenly become confused after 2 days of vomiting and
diarrhea. What laboratory result should the nurse report first to the RN?

A. Serum potassium 6mEq/L, serum sodium 126mnEq/L, and serum chloride 115mEq/L
B. Glucose tolerance results fasting 80 mg/dL, 1hr: 110mg/dL 2hr: 120 mg/dL, 3hr: 90 mg/dL
C. Negative Hepatitis B Surface Antigen, serum total biilirubin 0. 1 mg/dL
D. Troponin l < 0.1ng/mL and creatinine kinase MB (CK-MB) 2% of total 10 milliunits/L
A. Serum potassium 6mEq/L, serum sodium 126mnEq/L, and serum chloride 115mEq/L
While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?

A. Swab the oral cavity with a washcloth
B. Use oral swabs with normal saline
C. Provide a Yankauer tip for oral suction
D. Support the head with a small pillow
C. Provide a Yankauer tip for oral suction
The nurse is caring for a mother who is bottle-feeding and develops breast engorgement. Which intervention is most effective in reducing breast engorgement?

A. Wearing a tight-fitting bra
B. Applying hot packs to the breasts
C. Expressing milk from the breast by hand
D. Exposing the breasts to air
A. Wearing a tight-fitting bra
A 6-month old male with Bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates the nurse that he is experiencing Respiratory Distress?

A. Respiratory of 62 breaths/minute
B. Abdominal breathing
C. A high-pitched cry
D. Dry flushed skin
C. A high-pitched cry
During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the
best initial action by the nurse?

A. Count the right radial pulse rate
B. Reposition the oximeter clip
C. Document a pulse deficit
D. Count the apical pulse rate
B. Reposition the oximeter clip
Which client should the nurse assess first?
A. A young female client who reports that she is afraid of her roommate who is psychotic
B. An older client who is asking for a priest to offer Last Rites
C. A female client who is anxious about being discharged because she has no assistance at home
D. A client who is ambulating with partial weight-bearing after a total hip replacement
D. A client who is ambulating with partial weight-bearing after a total hip replacement
Nursing
The care of others
Science of nursing
the knowledge base for the care that is given
Art of nursing
skilled application of the knowledge base to help others reach maximum health and quality of life
Essence of nursing
caring for, caring with, and caring about people
Goals of nursing practice
1) to promote health
2) to prevent illness
3) to restore health
4) to facilitate coping with disability or death
Nurses accomplish these goals by using knowledge, skills, and critical thinking
4 competencies
1) cognitive abilities/skills
2) technical skills
3) interpersonal skills (communication)
4) ethical/legal skills
Nurses rely on these skills to achieve goals of practice
Health
Nurses promote this by maximizing the patient's own individual strengths
Health
Defined by the World Health Organization, one's health includes physical, social, and mental components and is not merely the absence of disease or infirmity
Health
Is a subjective state - a person may be medically diagnosed with an illness but still consider himself or herself healthy
Florence Nightingale
* Established the first school for nurses that provided both theory-based knowledge and clinical skill building
* Stressed the need to create a body of nursing knowledge separate from medical knowledge
* Recognized the influence of environment on health
* Identified personal needs of the patient and the role of the nurse in meeting those needs
* Established standards for hospital management
* Established a respected occupation for women
* Recognized the 2 components of nursing (health and illness)
* Recognized that nutrition is important to health
* Stressed the need for continuing education for nurses
* Identified that maintaining accurate records is important for nursing research
Nursing roles
* Caregiver
* Communicator
* Teacher/Educator
* Counselor
* Leader
* Researcher
* Advocate
* Collaborator
Nursing is recognized as a profession based on
* Well-defined body of specific and unique knowledge
* Strong service orientation
* Recognized authority by a professional group
* Code of ethics
* Professional organization that sets standards
* Ongoing research
* Autonomy
Nursing as a profession
* Uses an organized body of knowledge that is generated from research/theory and provides rationale for our nursing interventions/actions
* Uses nursing theory which is self-generated and draws from other disciplines/fields
Professional nursing organizations
* American Nurses Association (ANA)
* National League for Nursing (NLN)
* American Association for Colleges in Nurisng (AACN)
* National Student Nurses' Assocation (NSNA)
ANA
* Professional organization for RNs in the US
* Founded in the late 1800s
* Membership is comprised of the state nurses' associations to which individual nurses belong
* Establishes standards of practice, encourages research, and represents nursing for legislative actions
NLN
* Open to all people interested in nursing, including nurses, non-nurses, and agencies
* Established in 1952, its objective is to foster the development and improvement of all nursing services and nursing education
NSNA
Prepares students to participate in professional nursing organizations
AACN
* National voice for baccalaureate and higher degree nursing education programs
* The organization's goals focus on establishing quality educational standards; influencing the nursing profession to improve healthcare; and promoting the public support of baccalaureate and graduate education, research, and nursing practice
* National accreditation for collegiate nursing programs is provided (based on meeting standards) through this professional nursing organization by the Commision on Collegiate Nursing Education (CCNE)
Guidelines for Nursing Practice
* Scope and Standards of Practice defines the activities of nurses that are specific and unique to nursing
* Standards allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where healthcare is given
* Each nurse is accountable for his or her own quality of practice and is responsible for the use of these standards to ensure knowledgeable, safe, and comprehensive nursing care
Theory
* Composed of a group of concepts that describe a pattern of reality
* Statement that explains or characterizes a process, an occurence, or an event and is based on observed facts
* Arrange a group of related statements or concepts that give meaning to a series of events
Theories
* Derived through 2 principle methods: deductive reasoning and inductive reasoning
Nursing theories
* Developed to describe, explain, predict, and control
* Ultimate goal is to improve patient outcomes
Knowledge
An awareness of the reality one acquires through learning or investigation
Sources of knowledge
1) Traditional: passed from generation to generation (e.g. "We have always done it this way"
2) Authoritative: comes from an expert and is accepted (e.g. a senior staff member teaches a new nurse)
3) Scientific: new ideas tested and measured by research (evidence based practice)
Abraham Maslow
*1968
* Developed a hierarchy of basic human needs that can be used to consider which needs of a person are the most important at any given time
Human needs
* Humans are complex organisms, influenced by and responsive to both the internal and external environments
* Holistic nuring care allows the nurse to provide individualized and health-oriented care
Jean Watson
* Caritas Process
* Promote & restore health, prevent illness, and caring for the sick
* Holistic care: promote humanism, health, and quality of life
Nursing Theorists
* Hildegard Peplau (1952)
* Abraham Maslow (1968)
* Martha Rogers (1970)
* Dorothea Orem (1971)
* Sr. Callista Roy (1974)
* Madeline Leininger (1978)
* Patricia Benner (1989)
* Jean Watson
Hildegard Peplau
* 1952
* "mother of psychiatric nursing"
* Was a true pioneer in the development of the theory and practice of psychiatric and mental health nursing
* Interpersonal relationships theory
Martha Rogers
* 1970
* Science of Unitary Human Beings
* Promote health and well-being
Dorothea Orem
* 1971
* Self-care deficit theory
Sr. Callista Roy
* 1974
* Adaptation Model
* States that the individual is a set of interrelated systems that strive for balance
Madeline Leininger
* 1978
* Transcultural Nursing
Patricia Benner
* 1989
* Novice to Expert
* Stages of a clinical competence
Deductive reasoning
One examines a general idea and then considers specific actions or ideas
Inductive reasoning
One builds from specific ideas or actions to conclusions about general ideas
Holistic nursing care
Is based on considering all the patient's dimensions that affect how human needs are met in health and illness
Nursing research
* Improve care of patients by improving quality, cost effectiveness, and safety
* Broader study of people and nursing to enhance: education, policy development, ethics, and history
Evidence-based practice
* Nursing care provided that is supported by reliable research-based evidence
* The use of EBP mandates critical analysis and extensive, systematic reviews of research articles and findings to improve nursing interventions/actions
Evidence-based practice
* Review and critique research reports
* Identify level and strength of the evidence
* Make specific recommendation for practice: validate, change, and examples
RCTC's core integrating concepts
* Professionalism
* Critical thinking
* Caring
* Collaboration
* Nursing interventions
Professionalism
* Practice within the ethical and legal framework of the nursing profession
* Identify individual learning goals to promote learning for personal and professional development in a changing healthcare environment
Critical thinking
* Integrate evidence-based knowledge, clinical reasoning, and the nursing process to formulate safe nursing judgments when providing quality care
Caring
* Demonstrate an attitude of positive regard, respect for diversity, empathy and integrity when providing relationship centered care
Collaboration
* Collaborate with the patient, family, and health care team utilizing evidence-based health information/informatics to achieve quality outcomes
Nursing interventions
* Perform nursing interventions safely for individuals and families in a variety of settings
Role as a patient caregiver
4 primary objectives:
1) promote health
2) prevent illness
3) restore health
4) facilitate coping
Health
* Individually defined
* Integrates all the human dimensions
* Holistic care is important
Illness
* Response of the person to a pathological problem where level of functioning is changed
* Individually defined
* Disease: pathologic change in the structure or function of the body or mind
Stages of illness
Stage 1) experiencing symptoms
Stage 2) assume sick role
Stage 3) assume dependent role
Stage 4) recovery and rehabilitation
Chronic illness
* Permanent change
* Remissions
* Exacerbations
* Slow onset
* Requires education/support for rehabilitation
* Leading health problems in the world
* e.g. heart & lung conditions, arthritis, diabetes, HIV
Risk factors for illness
* Lifestyle
* Psychosocial
* Environmental
* Developmental
* Biologic
Levels of prevention
* Primary
* Secondary
* Tertiary
Primary level of prevention
* Health promotion
* Illness prevention
Secondary level of prevention
* Early detection
* Health maintenance
* Early intervention
Tertiary level of prevention
* Restoration
* Care of the dying
Health care delivery: nurses
* Largest employee group in health care
* Part of health care team
* Practice guided by nursing process
Classification of hospitals
* Public: nonprofit institutions are financed and operated by local, state, or national agencies. Patients admitted may not have insurance so services are provided at no cost or little cost to the patient. Tax revenue of public funds covers the cost
* Private: can be for profit or nonprofit, operated by communities, churches, corporations, and charitable organizations
* e.g. Mayo is private, nonprofit
* e.g. Olmsted is public
Frameworks for healthcare delivery
* Different methods are used to ensure continuity of care and cost-effective care as a patient moves through the healthcare system
* These methods include managed care systems, case management, primary healthcare
Federal & state regulatory agencies
* The Centers for Medicare and Medicaid Services (CMS)
* The Joint Commission - National Patient Safety Goals (NPSG)
* National Committee for Quality Assurance (NCQA)
Financial aspects of healthcare
* Medicare: part A (pays for hospitalization), part B (supplemental - can buy additional coverage)
* Medicaid: state-distributed federal money
* Group plans: HMO (health maintenance organization), PPO (preferred provider organization)
* Private insurance
* Long term care insurance
Trends in healthcare delivery
* Self-care focus
* Knowledgeable consumers
* Cost containment
* Fragmentation of care
* Aging & diversity of America
* Nursing shortage
Nurses' role in healthcare reform
* Cost containment
* Improved access
* Increased quality of services
* Political action (Nurses day on the hill)
Political action for healthcare reform
* Healthcare crisis is a societal problem that needs national political attention for a solution
* Nurse advocacy for our patient's well-being is an ethical obligation
* Political intervention is the key
* Nurses need to use their political muscle & credibility
Values
* Beliefs about the worth of something
* Formed during a lifetime
* Environment
* Family
* Culture
Care team
* Doctors
* Nurses
* Dietary
* Pharmacist
* Social worker
* Therapist
Professional values essential for nurses
* Foundation for nursing practice
* Guide "nurses interaction"
* 1998: The AACN identified 5 values that epitomize the caring, professional nurse
5 professional values identified by the AACN
* Altruism: concern for welfare and well-being of others
* Autonomy: right to self-determination; respect patient's right to make decisions
* Human dignity : respect for the inherent worth of individuals
* Integrity: the quality of being honest and having strong moral principles
* Social justice: upholding moral, legal, and humanistic principles
Professional values
* Value clarification:
- Process of understanding your own values and value system
- Involves choosing alternatives
- Prize which value involve feeling pride and happiness
- Acting by combining choice into one's behavior
Ethics
* Systematic inquiry into principles of right/wrong conduct of virtue/vice and of good/evil as they relate to conduct
Types of ethics
* Bioethics
* Clinical
* Nursing
Ethical conduct
* Begins in nursing school
* High-quality care based on professional standards of ethics
* Nurses identify and become familiar with bioethical standards for professional nursing conduct
Code of ethics
* Agency policies, and State and Federal privacy legislation dictate how patient information can be communicated (verbally and in writing)
* While most nurses are staunch advocates of a patient's right to privacy and confidentiality, many nurses thoughtlessly violate these rights every day (e.g. talking in elevators)
* Change in shift report: avoid gossip
Ethical theories
* Utilitarian
* Deontological
Principles of bioethics
* Autonomy
* Nonmaleficence
* Beneficence
* Justice
* Fidelity
Virtue of nurses
* Virtues are human excellencies, cultivated dispositions of character and conduct that motivate and enable us to be good human beings
Ethical theories: Utilitarian
* The rightness or wrongness of a particular action depends on the consequences
Ethical theories: Deontological
* The action is right or wrong and is independent of the consequences
Patient's Bill of Rights
* 1972 (revised in 2003 as the Patient Care Partnership)
* Rights and responsibilities of the patient while receiving care in the hospital
Patient's rights
* Able to see and copy their own medical record
* Update their health record
* Choose how to receive health information
* Right to accurate and easy to understand information
* Right to choose healthcare providers
* Right to respectful care
* Right to participate in treatment options
* Right to talk privately and have your information protected
* Righ to fair, fast, and objective review of any complaint that you have against caregivers
* Right to emergency services
Ethical decision making
* Ethical dilemmas
* Ethical distress
Ethical considerations
* Balance between benefit and harm
* Informed consent
* Family
* Relationships between caregivers and patients
* Professionalism
* Cost
* Culture and spiritual
* Power
Nurses advocacy
* Advocacy: protection and support of another's rights
* Represent patients
* Facilitate patient's decision making
Professional and legal regulation of nursing practice
* Nurse Practice Act: law affecting nursing practice
- Protects the public
- Lists violations
- Excludes untrained or unlicensed people
Legal issues
* Credentialing: way professional competence is ensured and maintained
- Accreditation
- Licensure
Accreditation
* Maintain minimum standards
* State Board of Nursing
Licensure
* Legal document
* Entry level competence
* State Board revoke of suspend
* NCLEX: National Council Licensure Examination
Legal safeguards
* Informed consent: confirm
* Contracts: exchange of promises (written or oral)
* Collective bargaining: unions or other organizations
* Competent practice: you're responsible for your own education and updating your practice with continuing educational hours; documentation
Legal safeguards
* Patient education
* Executing physician orders
* Documentation
* Adequate staffing
* Professional liability insurance
* Risk management program
* Incident report
Laws affecting nursing practice
* Occupational safety and health
* National practitioner data bank
* Reporting obligations
* Controlled substances
* Discrimination and sexual harassment
* Persons with disabilities
* Wills
* Legal issues r/t dying and death
Laws affecting nursing practice
* Sentinel events
* Good Samaritan Law
* Student liability
Sentinel event
* JCAHO
* An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
* Serious injury specifically includes loss of limb or function
* Needs immediate investigation and response
* E.g. a baby is stolen from the hospital
Bill of Rights for Registered Nurses
* Established due to decreased quality of care caused by inadequate staffing and decreased nurse satisfaction
* Improve workplace and ensure nurse ability to provide safe, quality patient care
* Empower nurses
Healthy People 2020: Leading Health Indicators
* Improve access to healthcare services
* Clinical preventative services
* Environmental quality
* Injury and violence prevention
* Maternal, infant, and child care
* Mental health and mental disorders
Healthy People 2020: Leading Health Indicators
* Nutrition, physical activity, and obesity
* Oral health
* Reproductive and sexual health
* Substance abuse
* Social determinants
* Tobacco use
NCLEX Question: a nursing instructor reviews the goals of Healthy People 2020 with students. Which statement by a nursing student indicates a need for further education?
1) "I know that nurses are key to the health indicator - Clinical Preventative Services."
2) "I would like to know more about the ways nurses can improve access to health services."
3) "I will study the Healthy People 2020 to learn more about how these indicators work."
4) "I know that nurses have a limited impact on the health indicators."
4) "I know that nurses have a limited impact on the health indicators."
NCLEX Analysis
* Questions will have application, analysis, synthesis or evaluation as the level of cognitive ability
* You will not get knowledge questions, instead you will get questions that have you apply your knowledge
* There is a strategy that can be learned from each question.
Common nursing virtues
* Competence
* Compassionate caring
* Subordination of self-interest to patient care
* Self-effacement
* Trustworthiness
* Conscientiousness
* Intelligence
* Practical wisdom
* Humility
* Courage
* Integrity
Nursing code of ethics
* Framework (to make decisions): professional expectations
* Goals and values of profession
* Protects patients
* Nursing Standards of Practice: 1991 standards of professional performance and standards of care
Good Samaritan Law
* Protects health practitioners when giving emergency aid
Student Liability
* Responsible for their own acts
* Be prepared to know agency policies and procedures
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
* The intent of this initiative is to provide a standardized survey instrument and data collection method to get patients perspective on hospital care
* National standard for patient satisfaction
* Designed to include public reporting of results
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
* Federal mandated organization
* Specifies that nursing care data r/t patient assessments, nursing diagnoses or patient needs, nursing interventions, and patient outcomes are permanently integrated into the patient record
* Each nurse is expected to practice according to local policies and professional standards
Cultural influences
* Peoples' values and beliefs about health, illness, and care for an illness
* Develop from cultural and ethnic influences
Cultural norms of the healthcare system
* Beliefs
* Practices
* Habits
* Likes
* Dislikes
* Customs
Beliefs
* Standardized definition of health and illness
Practices
* Maintenance of health and prevention of illness
Habits
* Use of a systematic approach and problem-solving methodology
Nurses need to:
* Develop cultural self-awareness
* Develop cultural knowledge
* Accommodate cultural practices in healthcare
* Respect culturally based family roles
* Avoid mandating change
* Seek cultural assistance
Culturally competent nursing care
* Care is planned and given in a way that is sensitive to needs
* Healthcare system is a culture with customs, rules, values, and a language of its own
* Cultural assessment
* Guidelines for nursing care
Culturally competent care
* Physiological characteristics
* Psychological characteristics
* Reactions to pain
* Mental health
* Gender roles
* Language and communication
* Orientation to space and time
* Food and nutrition
* Family support
* Socioeconomic status
Ethinicity
* Sense of identification
* Share unique cultural and social beliefs
Race
Based on specific characteristics (e.g. skin color, hair color, facial features)
Stereotyping
Assuming groups are alike
Ethnocentrism
Belief that one's ideas, beliefs, and practice are the best or superior
Cultural assimilation
One's values are replaced by the values of the dominant culture
Growth
Increase in body size or changes in body cell structure, function, and complexity
Development
Orderly pattern of change in structure, thoughts, feelings or behaviors resulting from maturation, experiences, and learning
Principles of growth and development
* Are orderly and sequential as well as continuous and complex
* Follow regular and predictable trends
* Differentiated and integrated
* Different aspects occur at different stages and at different rates, and can be modified
* Pace is specific for each person
* Physical and psychological skills and maturation vary among people
5 major components of growth and development
* Physiological: body function
* Cognitive: intelligence, thinking
* Psychosocial: emotional, reactions with environment and other people
* Moral: sense of right and wrong
* Spiritual: religious, sense of correctness with inner self
Factors influencing growth and development
* Genetic heredity
* Prenatal
* Individual and caregiver factors
* Environment
* Nutrition
* Health and illness
* Culture
Theory of psychoanalytic development
* Sigmund Freud
* Emphasizes the effect of instinctual human drives on behavior
* 4 major components
* 5 stages
* If not resolution in one stage, fixation follows with arrested development
* Ego is defense mechanism
Theory of cognitive development
* Jean Piaget
* 4 stages of from birth to adolescent
* Framework for how children learn rules
* Each stage transforms and supersedes the one before
* Stages are universal (affects all cultures and people)
Theory of psychosocial development
* Erik Erickson
* 8 stages from infancy to late adulthood
* Each stage has major crisis
* Lack of resolution prevents aligning to develop fully
* Never too late for resolution of any stage crisis
Theory of moral development
* Lawrence Kohlberg
* Carol Gilligan
Theories of aging
* Genetic theory of aging: genetics and hereditary
* Immunity theory of aging: immune system
* Cross-linkage theory: chemical reaction that damages DNA and leads to cell death
* Free radical theory: free radicals are formed during cellular metabolism which have an adverse effect on adjacent cells
Middle adulthood (40-65): generation vs. stagnation
* Awareness of aging process with some increase of health problems
* Maturation and acceptance of family roles, careers, economic responsibilities
* Some crises: aging, death of loved ones
Major health concerns for middle adult
* Heart/pulmonary disease
* Cancer/strokes
* Diabetes mellitus/obesity
* Alcoholism/depression
* Accidents
Role of nurse: middle adult
* Health maintenance and promotion
* Greater emphasis on both anticipatory guidance counseling
* Teaching about illnesses, grand-parenting, retirement, losses, stress reduction
Older adult: integrity vs. despair
* Older than 65 years
* By 2030, 20% of the population will be older than 65
* Older women outnumber older men
* Reminiscence about life events provides a sense of fulfillment and purpose
Gerontology
The scientific and behavioral study of all aspects of aging and its consequences
Myths about older adults
* Old age begins at 65 years
* Most older adults live in nursing homes
* Most older adults are sick
* Old age means mental deterioration
* Older adults are not interested in sex
* Older adults don't care how they look
* Bladder problems are a problem of aging
* Older adults do not deserve aggressive treatment for serious illness
Normal physiologic changes of older adults
* Balance declines
* Decreased ability to maintain homeostasis
* Integument: wrinkles and sagging skin, change in pigmentation
* Decreased sight and hearing
* Decrease in SQ tissue and weight, muscle mass, and strength
* Bone demineralization
* Joints stiffen
* Diminished lung capacity and less effective cough
* Decreased blood flow and blood vessel elasticity
* Less efficient venous return
* Fatty plaque deposits
* Heart valves thicken
* Decreased GI motility and digestive juices
* Ab. muscles weaken
* Swallowing reflex less effective
* Decreased bladder capacity, muscle tone, and prostate gland enlarges
* Decrease in response time, balance, coordination, and learning speed
* Sleep time at night shortens
* Temp. regulation and pain/pressure perception become less efficient
Major losses
* Death of loved ones
* Relocation
* Job loss/retirement
* Depression from social isolation
Suicide
* In 2014, the highest suicide rate (19.3) was among people older than 85
* Second highest rate (19.2) was among people ages 45-64 years
* Younger groups have had consistently lower suicide rates than middle-aged and older adults (11.6% ages 15-24 in 2014)
Assessment/teaching for aging adult
* Nutrition: less food, more often, low salt/fat/sugar
* Regular exercise
* Encourage independence: teach proper use of canes and walkers
* Encourage regular socialization
* Medications: teach proper use and correct dosage
* Protect from injury: falls, hypothermia, assess living situation and remove throw rugs, place furniture safely, look at walking shoes
Factors affecting health in the community
* Support systems
* Community health care structure
* Environment
* Economic resources
Community based care
*Healthcare provided to people who live within a defined geographic area
* Each community is unique and is defined by the people, area, social interactions, and common ties
* Centered on individual and family healthcare needs
Community based healthcare services
* Home health care
* Hospice: 6 months or less to live
* Respite care
* Community centers and clinics
* Day care programs
* Parish nursing
* Meals on wheels
Role of the nurse for the elderly
* Health restoration
* Health maintenance
* Health promotion
* Dying with dignity
Health promotion
* Nursing interventions done to promote the level of health the patient is currently experiencing
* E.g. immunizations, screenings, teachings
Health restoration
* Nursing interventions that are focused on restoring the patient back to their previous level of health
* Generally done after the patient has become ill
* Includes medications, surgery, treatments, etc.
Health maintenance
* Nursing interventions that are focused on maintaining the patient's level of health
Need to know in Patient Safety
Developmental levels
Mobility, sensory, and cognitive status
Lifestyle choices
Special risks found in health care setting
Patient Safety according to QSEN
Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Patient Safety according to IOM
New standard for quality care—care that is free of unintended injury from acts of commission or omission, in any setting in which it is delivered.
Patient Centered Care according to QSEN
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.
Purpose of the National Patient Safety Goals (TJC website)
The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
Risks for Infant, Toddler, and Preschooler
Injuries, lead poisoning, accidents due to particular stage of growth--such as oral activity and children possibly ingesting dangerous substances or choking
Risks for the School-Age Child
Different environments outside of the home, such as school, school transportation, after school activities, etc. Strangers, sports activities, bicycle related injuries.
Risks for the Adolescent
greater independence and separate emotionally from family; tension associated with physical and psychological changes and peer pressures can lead to risk-taking behaviors like smoking or drugs; motor vehicle accidents
Risks for the Adult
lifestyle habits: alcohol/drug use, and smoking; stress leading to accidents or illnesses, such as headaches, gastrointestinal disorders, and infections
Risks for the Older Adult
physiological changes leading to greater fall risk and other types of accidents such as burns and car accidents
Risks within the Healthcare Setting
Medical errors: infection, bed sores, and failure to diagnose and treat in time; medication errors; falls, client-inherent accident; procedure-related accidents; equipment-related accidents
Inflammation
A protective reaction;
Can be caused by nonliving agents i.e. heat, trauma;
Always present with infection;
Infection occurs only through superimposed evasion of microorganisms;
It establishes an environment for healing
Infection
Involves invasion of tissue or cells by microorganisms (bacteria, fungi, or viruses)
Always has inflammation present
Often reveals altered lab values ( i.e. WBCs, positive cultures)
Infection and Inflammation
can be local, systemic, acute or chronic
Recognizing Infection
Local or systemic
Patient information, clinical appearance (objective and subjective)
Vital signs
Lab values
CBC (Complete Blood Count)
Culture reports
Recognizing Inflammation
Swelling
Redness--Hyperemia
Heat
Pain/Tenderness
Loss of Function
Functions of red blood cells (erythrocytes)
carry oxygen from the lungs to body tissues and transfer carbon dioxide from the tissues to the lungs. Oxygen transfer is accomplished via the hemoglobin contained in RBC's. Hemoglobin combines readily with oxygen and carbon dioxide.
Normal values white blood cells (leukocytes)
normally 5000 to 10,000/microliter, can rise up to 15,000 to 20,000/microliter and higher during inflammation, high white blood cell count can indicate infection
Functions of white blood cells
involved in cellular response of inflammation upon arrival at site; WBC pass through blood vessels and into the tissues; through phagocytosis, neutrophils and monocytes ingest and destroy microorganisms and other small particles
High red blood cell count (polycethemia)
increases in the RBC count occur at high altitudes because less atmospheric weight pushes air into the lungs, causing a decrease in the partial pressure of oxygen and hypoxia. With strenuous physical training, increased muscle mass demands more oxygen.
Normal values of red blood cells
4 to 6 million/microliter
Low red blood cell count (anemia)
can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. Red blood cells live for approximately four months in the bloodstream
Normal levels of platelets
150,000 to 400,000/microliter
Functions of platelets (thrombocytes)
prevent bleeding
Chain of Infection
Infection occurs in a cycle that depends on the presence of:
Infectious agent or pathogen, Reservoir or source for pathogen growth, portal of exit from the reservoir, mode of transmission, portal of entry to a host, susceptible host
Infectious agent
microorganisms include bacteria, viruses, fungi, and protozoa; can cause disease when there is sufficient number, adequate virulence, ability to enter and survive the host, and susceptibility of the host
Reservoir
place where a pathogen can survive but may not multiply, may be in food, oxygen, and water; factors that affect bacteria growth are temperature, pH, and light (organisms can thrive in the dark)
Portal of Exit
for microorganisms to grow and multiply they must exit their host, portals of exits include blood, skin, and mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
Modes of Transmission
the specific way a disease is transmitted, most common: (unwashed hands) direct (person-person), physical contact, indirect (susceptible host to inanimate object), droplet (large particles that travel up to 3 ft), airborne, vehicles, vector (mosquitos)
Portal of Entry
organism enter the body through the same routes they use for exiting
Susceptible Host
depends on the individual degree of resistance to a pathogen (immune response). Factors that influence susceptibility are age, nutritional status, presence of chronic disease, trauma, and smoking
pathogenicity
the ability of a pathogen to produce an infectious disease in an organism
localized infection
localized symptoms (wound infection) pain and tenderness and redness at the wound site
systemic infection
infection that affects the entire body instead of just a single organ or part, can become fatal if left untreated
inflammatory response
protective reaction that serves to neutralize pathogens and repair body cells
nursing actions that control or eliminate infections in the clinical setting
properly administering antibiotics, monitoring response to drug therapy, and using proper hand hygiene and standard precautions; supportive therapy would include proper nutrition and rest
Role of nurse in infection control
Assess patient's defense mechanisms: age, nutritional status, stress, disease process; susceptibility and knowledge of infections;
"Risk for Infection": lab data and clinical appearance;
Consult Infection Control Practitioner: clients with infection
Nursing Care Infection Control-wound care
Handwashing
Use gloves
Elevate foot
Aseptic technique for dressing change
Discard contaminated dressing, linens, etc. properly
Administer medications
Management of fever
Rest
Maintain glucose within normal range
Healthy diet
Teach infection control
Acute/Transient Pain
protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response
Chronic/Persistent Pain
not protective and serves no purpose, lasts longer than anticipated, does not always have an identifiable cause, and leads to great personal suffering, can be cancerous or noncancerous)
Chronic/Episodic
pain that occurs sporadically over an extended duration of time, may last for hours, days, or weeks (migraine headaches)
Cancer pain
can be acute and/or chronic, sometimes nociceptive and/or neuropathic; usually due to tumor progression and its related pathological process, invasive procedures, toxicities or treatments, infection , and physical limitation--at actual site or referred
Inferred pain by pathological process
Nociceptive pain--somatic and visceral and neuropathic pain
Nociceptive Pain
Damage to bone, soft tissue, or internal organs
Usually responsive to nonopioids and/or opioids
Types of nociceptive pain: somatic pain and visceral pain
Somatic Pain
Arises from bone, joint, muscle, skin or connective tissue
Usually aching or throbbing in quality and is well localized
Visceral Pain
Arises from viscera, such as the GI tract and pancreas;
Described as squeezing, cramping pain, shooting;
May be due to obstruction of hollow viscous, which causes the cramping and poorly localized pain
Neuropathic Pain
Abnormal processing of sensory input by the peripheral or central nervous system;
Treatment usually includes adjuvant drugs;
A physical cause for reports of excruciating pain may not be evident on examination
Idiopathic Pain
chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
factors that influence pain
physiological factor: age, fatigue, genes, neurological function; social factors: attention, previous experience, family and social support; Spiritual factors; psychological factors: anxiety, coping style; Cultural Factors: meaning of pain, ethnicity
Pain Assessment
Factors influencing the pain experience:
Location
Intensity
Quality
Pattern
Aggravating/relieving factors
Medication history
Pharmacological Measures Nursing Responsibilities (pain management)
Assess pain
Determine when to administer analgesics
Select the appropriate analgesic
Evaluate effectiveness of analgesics
Monitor and manage medication side effects
Suggest changes
Consider the needs of special populations (mentally ill, cognitively impaired, etc)
nursing role in pain management
Direct clinical care
Patient/family teaching
Education of colleagues
Identify system barriers
Factors Affecting Oxygenation
physiological, developmental, lifestyle, environmental
Physiological Factors affecting oxygenation
reduced oxygen carrying capacity, reduced inspired oxygen concentration, hypovolemia, higher metabolic rate, impaired chest wall movement-pregnancy, obesity, musculoskeletal abnormalities, trauma, neuromuscular diseases, central nervous system alterations, influences of chronic disease
Developmental Factors affecting oxygenation
infants and toddlers (upper respiratory tract infection), school age children and adolescents (smoking-respiratory infections), young and middle age adults (lifestyle factors-affect cardiopulmonary health)
The older adult and oxygenation
trachea & large bronchi become enlarged from calcification of the airways; alveoli enlarge, reducing the surface area available for gas exchange; the number of cilia is reduced, causing a decrease in the effectiveness of the cough mechanism-which can cause respiratory infection
Lifestyle factors affecting oxygenation
habits such as cigarette smoking or unhealthy diets; nutrition, exercise, smoking, substance abuse, stress
environmental factors affecting oxygenation
pulmonary disease is higher in smoggy, urban areas than in rural areas; patient's workplace --occupational pollutants include asbestos, talcum powder, dust, and airborne fibers
Alterations in Respiratory Functioning
Atelectasis
Aspiration
Hyperventilation
Hypoventilation
Hypoxia
Atelectasis
collapse of alveoli which prevents normal exchange of oxygen and carbon dioxide
Aspiration
occurs when fluids are breathed into the lungs or airways leading to the lungs
Hyperventilation
a state of ventilation in excess of that required to eliminate the carbon dioxide produced by cellular metabolism
Hypoventilation
occurs when alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide
Hypoxia
inadequate tissue oxygenation at the cellular level, results from a deficiency in oxygen delivery or oxygen utilization at the cellular level-life threatening condition
Signs and symptoms of Hypoxia
apprehension, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes, increased pulse rate and increased rate and depth of respiration
Cyanosis
blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries-late sign of hypoxia
Objective nursing assessment as related to oxygenation
Inspection, Palpation, Percussion, Auscultation;
Laboratory and diagnostic tests
Hemoglobin
Pulse oximetry
Arterial blood gases
Arterial blood gas analysis
most effective way to evaluate acid-base balance and oxygenation, deviation from normal value will indicate that the client is experiencing an acid-base imbalance; measure of: pH, PaCO2, PaO2, oxygen saturation, and HCO3-
Inspection as related to oxygenation
Respiratory rate, rhythm, depth, breathing pattern
Skin color
Breathing posture
Muscles used in breathing
Clubbing of finger nails
Capillary refill
Level of consciousness
Diagnostic Tests as related to oxygenation
Hemoglobin Levels: 13.5-18g/dl males, 12-16g/dl female
Chest x-ray
Pulmonary function studies
Lung Scan
Bronchoscopy
Throat culture
Sputum specimens
Pulse oximetry
Pulse Oximetry
Non-invasive
Measures arterial oxygen saturation
SpO2 Normal is > 95%
Ensure accuracy: validate with patient heart rate
Ensure accuracy: determine patient's hemoglobin level
Continuous, intermittent, or during ambulation
pH
Normal arterial blood pH is 7.35 - 7.45; acidic is less than 7.35 and alkaloid is greater than 7.45
PaCO2
partial pressure of carbon dioxide in arterial blood and is a reflection of pulmonary ventilation; normal range is 35 - 45 mm Hg, hyperventilation occurs when the PaCO2 is less than 35mm Hg; hypoventilation occurs when the PaCO2 level is more than 45mm Hg
PaO2
partial pressure of oxygen in arterial blood; normal range is 80-100mm Hg; less than 60mm Hg leads to anaerobic metabolism, resulting in acidic production and metabolic acidosis; hyperventilation also causes a decrease in PaO2, or respiratory alkalosis
Oxygen Saturation
the point at which hemoglobin is saturated by O2, normal range is 95%-99%
nursing action for atelectasis
hypoventilation occurs so best action is to help improve tissue oxygenation, restoring ventilatory function, treating the atelectasis, and achieving acid base balance. use of incentive spirometer, deep breathing and coughing, pursed lip breathing
nursing action for hypoventilation
same as atelectasis, add diaphragmatic breathing-if possible, check on oxygen therapy
nursing action for aspiration
positioning to avoid aspiration, coughing to clear sputum/fluid, maintain a clear airway
nursing action for hyperventilation
oxygen therapy, diaphragmatic breathing to relax patient, incentive spirometer
nursing action for hypoxia
oxygen therapy, incentive spirometer, diaphragmatic breathing
general nursing actions in regards to oxygenation
Auscultate lung sounds
- Monitor RR, depth, rhythm
-Monitor vital signs
-Monitor O2 sat, ABGs
-Monitor mental status
-Position for best lung expansion, elevate HOB
-Reposition regularly
-Ambulate patient
-Provide oxygen
-Provide humidification
-Increase fluid intake
-Ensure adequate diet
-Provide good oral hygiene
-Provide emotional support
-Utilize incentive spirometry
-Administer medication
-Provide education
-Prevent and recognize complication
Principles of Oxygen Therapy
Oxygen should be treated as a drug
Expensive
Side Effects
Safety issues
Verify 6 Rights of medication
Factors that influence the quality and quantity of sleep
Physical Illness
Drugs/Medications
Lifestyle
Emotional Stress
Environment
Nutrition
Sensory Deprivation
hypersomnolence
sleep problems from inadequacies in either quantity or quality of nighttime sleep on a daily basis
insomnia
a symptom clients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep (most common complaint)
sleep apnea
disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep; 3 types: central, obstructive, and mixed apnea
obstructive sleep apnea
occurs when muscles or structures of the oral cavity or throat relax during sleep; the upper airway becomes partially or completely blocked, diminishing (hypopnea) nasal airflow or stopping for as long as 30 seconds
central sleep apnea
involves dysfunction in the brain's respiratory control center, the impulse to breathe temporarily fails, and nasal airflow and chest wall movement cease
narcolepsy
dysfunction of mechanisms that regulate the sleep and wake states (may fall asleep uncontrollably at times)
sleep deprivation
result of dyssomnia, causes may be illness, emotional stress, medications, environmental substances, and variability in the timing of sleep due to shift work
parasomnias
sleep problems that are more common in children than in adults--may have link to SIDS, in older children: somnambulism, night terrors, nightmares, nocturnal enuresis, body rocking, and bruxism (tooth grinding)
measures to promote sleep
Adequate assessment
Plan activities to maximize time for rest and sleep
Provide comfort measures
Establish sleep environment
Patient education
interventions to promote sleep
Plan activities to maximize time for rest & sleep
Provide comfort measures
Establish sleep environment
Establish sleep routine
Avoid stimulants
Avoid exercise 2-3 hours before bedtime
Pharmacological approaches
sleep apnea treatment
Behavioral Therapy
-weight reduction
-avoidance of alcohol, tobacco, sleeping pills
-positional therapy

Physical or Mechanical Therapy
-dental appliance
-positive airway pressure device
nursing process
professional nurse's approach to identify, diagnose, and treat human responses to health and illness; 5 steps: assessment, diagnosis, planning, implementation, and evaluation
nursing assessment
deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
steps of the nursing assessment
1) collection and verification of data from a primary source, and secondary sources
2) the analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care
database
built during assessment, concerns the client's perceived needs, health problems, and responses to these problems
sources of data
client, family and significant others, health care team medical records, nurse's experience, other records and literature
subjective data
client's verbal description of their health problems, will include feelings perceptions, and self-report of symptoms
objective data
observations or measurements of a client's health status
nursing health history
data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
data analysis
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.
medical diagnosis
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures
nursing diagnosis
clinical judgment about individual, family, or community responses to actual & potential health problems or life processes; statement describing the client's actual or potential response to a health problem that nurse is licensed and competent to treat.
collaborative problem
an actual potential physiological complication that nurses monitor to detect the onset of changes in a client's status
North American Nursing Diagnosis Association (NANDA)
established to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
defining criteria
the clinical criteria or assessment findings that support an actual nursing diagnosis
clinical criteria
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
actual nursing diagnosis
describes human responses to health conditions or life processes that exist in an individual, family, or community--acute pain
risk diagnosis
describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community
health promotion nursing diagnosis
a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise
diagnostic label
the name of the nursing diagnosis as approved by NANDA International, it describes the essence of a client's response to health conditions in as few words as possible
related factors
a condition or etiology identified from the client's assessment data, associated with the client's actual or potential response to the health problem and can change by using nursing interventions
etiology
the cause of a disease, and is alway within the domain of nursing practice and a condition that responds to nursing interventions
planning
3rd step of nursing process; a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
priority setting
the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
goal
an aim, intent, or end; a broad statement that describes the desired change in a client's condition or behavior
expected outcomes
measurable criteria to evaluate goal achievement
client-centered goal
specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function
short-term goal
an objective behavior or response that you expect a client to achieve in a short time, usually less than a week
long-term goal
an objective behavior or response that you expect a client to achieve over a longer period; usually over several days, weeks, or months
guidelines for writing goals
client-centered
singular goal or outcome
observable
measurable
time-limited
mutual factors
realistic
types of interventions
independent nursing, dependent nursing, and collaborative interventions
independent nursing intervention
actions that a nurse initiates
dependent nursing intervention
physician initiated, actions that require an order from a physician or another health care professional
collaborative intervention
interdependent, therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
nursing care plan
enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care
scientific rationale
the reason that you chose a specific nursing action, based on supporting evidence
implementation
4th step of nursing process; formally begins after the nurse develops a plan of care
nursing intervention
any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
Implementation skill of nursing process
cognitive skills: application of critical thinking to nursing process
interpersonal skills: effective for nursing action-developing a relationship
psychomotor skills: integration of cognitive and interpersonal skills
evaluation
last step of nursing process; used to determine if after application of the nursing process, the client's condition or well-being improved (used to determine if you met expected outcomes, not if nursing interventions were completed)
standard of care
minimum level of care accepted to ensure high quality of care to clients; defines the types of therapies typically administered to clients with defined problems or needs
Oxygen Saturation
Normal PaO2 80-100 mm Hg
Normal O2 saturation > 95%
(SaO2)
Compare to pulse oximetry reading
(SpO2)
Acid Base Imbalances
Normal pH 7.35-7.45
Acidosis <7.35
Alkalosis >7.45

Lungs regulate pH using CO2
Kidneys regulate pH using HCO3
Respiratory Acidosis
pH Below 7.35

PaCO2 Above 45

HCO3 Normal

Common Example: Hypoventilation
Respiratory Alkalosis
pH Above 7.45

PaCO2 Below 35

HCO3 Normal

Common Example: Hyperventilation
factors affecting personal hygiene
-culture
-socioeconomic class
-spiritual practices
-developmental level
-state of health
-personal preferences
culture and person hygiene
-cleanliness and hygiene can differ between cultures
-in some cultures it is considered unclean to not shower daily and use deodorants
-some people find weekly baths sufficient and don't use deodorants
-bathing can also be a private or communal activity
socioeconomic class and culture and hygiene
-financial resources can affect how clean a person is
-people may not even have access to a bath or shower or can afford soap and shampoo
Spiritual practices and hygiene
-religious beliefs may affect hygienic practices
-in orthodox jews, ritual baths are required for women after childbirth and menstruation
-some culture prohibit modern facilities which hinder their bathing
developmental level and hygiene
-children learn hygiene while growing up and they learn from family practices
-adolescents may bathe more frequently due to concerns of appearance and acne
-as age increases, time spent bathing decreases which can lead to skin conditions or problems
health state and hygiene
-disease, surgery, or injury may reduce a persons ability to perform hygiene measures or motivation to follow usually hygiene habits
-weakness, dizziness and fear of falling may prevents a person from bathing or showering, especially lower extremities
personal preferences of hygiene
-some people prefer showers over baths and vice versa
-some use bathing as a form of relaxation
-people ideas of cleanliness differ
-women can use hygienic products following intercourse to promote cleanliness
questions to ask while examining skin
-How long have you had this problem?
-does it bother you?
-how does it bother you?
-have you found anything helpful in relieving these symptoms?
factors to consider while examining skin
-cleanliness
-color
-temperature
-turgor
-moisture
-sensation
-vascularity
-evidence of lesions
early morning care
-assist patient with toileting
-provide comfort measures to refresh patient to prepare for the day
-wash face and hands
-provide mouth care
Morning (AM) care
(after breakfast)
-bathing
-back massage
-special skin measures
-hair care and cosmetics
-dressing
-positioning for comfort
-refreshing or changing bed linens
-tidying up bedside
afternoon (PM) care
-toileting
-handwashing
-oral care
-straighten bed linens
-help patient with mobility to reposition
hours of sleep care
-offer assistance with toileting, washing, and oral care
-offer back massage
-change any soiled bed linens or clothing
-position patient comfortably
-ensure that call light and other objects patient requires are within reach
as needed (PRN) care
-offer individual hygiene measures as needed
-change clothing and bed linens of diaphoretic patients
-provide oral care every 2 hours if indicated
self care patients
-patients who are capable of managing their personal hygiene independently once oriented to the bathroom
-still offer back massage and spend time assessing the patients day to day needs
Partial care patients
-receive morning hygiene care at the bedside or seated near a sink in the bathroom.
-they usually require assistance with body areas that are difficult to reach
Complete care patients
-require assistance with all aspects of personal hygiene
-a complete bed bath is done or patient is taken to shower
bed bath
-provide materials needed
-provide privacy
-remove top linens and replace with bath blanket
-place cosmetics in convenient place
-assist patients who cannot bathe themselves completely
reasons for providing back massage
-acts as a general body conditioner
-relieves muscle tension and promotes relaxation
-provides opportunity for nurse to observe skin for signs of breakdowns
-improves circulation
-may decrease pain, distress, and anxiety
-may improve sleep quality
-provides a means of communication through use of touch
purpose of bathing
-cleanses skin
-acts as conditioner
-relaxation
-promotes circulation
-serves as musculoskeletal exercise
-stimulates rate and depth of respirations
-promotes comfort
-provides person with sensory input
-helps improve self-image
-strengthens nurse-patient relationship
physical assessment of oral cavities
look for:
-dental caries
-periodontal disease
-other oral problems (thrush, plaque buildup)
-identify actual or potential problems
-identify appropriate nursing measures
-carry out plan
administering oral hygiene
-moistening the mouth
-cleaning the mouth
-caring for dentures
-toothbrushing and flossing (place brush at 45 degree angle to gum line)
-using mouthwashes
care of eyes
-clean from inner to outer canthus with wet, warm cloth, cotton ball or compress
-use artificial tear solution or normal saline every 4 hours if blink reflex is absent
-care for eyeglasses, contact lens or artificial eye if indicated
ear and nose care
-Wash external ear with washcloth-covered finger; do not use cotton-tipped swabs.
-Perform hearing aid teaching and care if indicated.
-Clean nose by having patient blow it if both nares are patent.
-Remove crusted secretions around nose by applying warm, moist compress.
providing hair care
-identify patients usual hair and scalp care practices and styling preferences
-note any history of hair or scalp problems (dandruff, hair loss, baldness)
-treat any infestations
-groom and shampoo hair
-care for beards and mustaches
-assist with unwanted hair removal
nail and foot care
-asses nails for color and shape, intactness and cleanness and ternderness
-check history of foot and nail problems
-soak nails and feet and assist with cleaning and trimming
-massage feet to promote relaxation and comfort
-provide diabetic foot care if indicated
perineal and vaginal care
-assess for problems
-perform physical assessment of male and female genitalia
-perfomr perineal care in a matter-of-fact and dignified manner according to procedure
-cleanse vaginal area with plain soap and water
ensuring bedside safety
-bed is in lowest position
-bed position is safe for patient
-bed controls are functioning
-call light is functioning and always within reach
-side rails are raised if indicated
-the wheels or casters are locked
The institute of medicine (IOM)
-A branch of the National Academy of Sciences whose goal is to advance and distribute scientific knowledge with the mission of improving human health
-identifies safety as an organizational priority and emphasized that medical errors are more frequently due to system problems rather than human error
-recognized need for renewed focus on safety
zero harm in healthcare initiative
-preventing falls, pressure ulcers, hospital acquired infections
-process improvement
-developing and adopting a culture of safety
-accountability for safety and quality
-getting rid of complications from care
-preventing harm for employees
-accreditation in compliant hospitals/facilities
The Joint commission role in patient safety
-The product of individual & group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization's commitment to quality & patient safety
-Identify patients correctly
-use medicines safely
-use alarms safely
-prevent infection
-identify patient safety risks
-prevent mistakes in surgery
factors that affect safety
-developmental considerations (age,risk of cross infection, taking universal precautions)
-lifestyle
-social behavior
-environment
-mobility
-sensory perception
-knowledge
-ability to communicate (SBAR)
-physical and psychosocial health state
developmental considerations and safety
-each developmental level carries its own risks
-healthcare needs and safety risks change as people progress from infancy to the older adult stage
-physical and cognitive changes reflect the sequential development stages
lifestyle and safety
-certain occupations and recreational activities place people in more hazardous situations
ex:
-healthcare staff who suffer sleep deprivation due to extended work hours and variable shifts assignments are more likely to commit errors and be a factor in adverse events
social behavior and safety
-people who are inclined to take risks and jeopardize their safety
(failure to wear seatbelts or follow safety precautions)
-stress can precipitate an unhealthy lifestyle
-use of drugs
-vulnerable populations
environment and safety
-risk for exposure to potentially unhealthy substances in the environment
-living in high-crime neighborhoods
-facilities must have up-to-date worksite analyses to recognize patterns of violence
-lack of star handrails
-poor stair design
-lack of bathroom grab bars
-dim lighting or glare
-obstacles/tripping hazards
-slippery or uneven surfaces
-psychoactive medications
-improper use of assistive devices
mobility and safety
-a limitation in mobility is unsafe
-an older adult with an unsteady gait is more prone to falling
-people with partial paralysis
-people who use supportive devices like canes, walkers and wheelchairs
-people who recently have had surgery or a prolonged illness that affect the patients mobility
-nurses must assess a patients risk for injury with a view toward maintaining independence and fostering self-esteem while providing a safe and predictable environment
sensory perception and safety
-alterations in sensory perception can have a devastating affect on safety
-impairment in sight, hearing, smell, taste, or touch can reduce a persons sensitivity to the environment
ex:
-not being able to see objects that can be tripped over
- inability to hear alarms, horns, sirens, or healthcare instructions
-not being able to smell gas leaks or smoke
-loss of taste may cause eating of tainted or unsafe food
knowledge and safety
-awareness of safety and security precautions is crucial for promoting and maintaining wellness throughout the lifespan
-patients need instructions to adhere to a medical regimin or to follow safety precautions when oxygen is in use
-patients require certain amount of knowledge to manage new equipment and unfamiliar procedures
-they need to be able to identify potentially threatening circumstances
-patient teaching is crucial
ability to communicate and safety
-ability to communicate is basic to many safety practices
-nurses must assess any factors that may influence the patients ability to receive and send messages
-fatigue, stress, medications, aphasia, and language barriers are examples of factors that can affect communication
physical health state and safety
-anything that affects the patients health state can potentially affect the safety of the environment
-healthcare of chronically ill or weakened patients includes preventing accidents as well as promoting wellness and restoration of healthy state
psychosocial health state and safety
-stressful situations tend to narrow a persons attention span and make the person more prone to accidents
-stress can occur over a long period of time but effects tend to be more devastating persons later years (less adaptive and coping capacity)
-depression may result in confusion and disorientation, accompanied by reduced awareness or concern about environmental hazards
nursing process for fall prevention
-assess for history of falls or accidents
-note assistive devices
-be alert to history of drug or alcohol abuse
-obtain knowledge of family support systems and home environment
-assess specific risk factors, the environment, and the person (pt, caregiver, healthcare team, family)
nursing interventions to prevent falls
-Complete a risk assessment.
-Indicate risk for falling on patient's door and chart.
-Keep bed in low position.
-Keep wheels on bed and wheelchair locked.
-Leave call bell within patient's reach.
-Instruct patient regarding use of call bell.
-Answer call bells promptly.
-Leave a night light on.
-Eliminate all physical hazards in the room (clutter, wet areas on the floor).
-Provide nonskid footwear.
Leave water, tissues, bedpan/urinal within patient's reach.
-Document and report any changes in patient's cognitive status to the physician and other nurses at the change of shift.
-Use alternative strategies when necessary instead of restraints.
-As a last resort, use the least restrictive restraint according to agency policy.
If restraint is applied, assess patient at the required intervals.
risk of restraints
-physical restraints can increase the possibility of serious injury due to a fall (they do not prevent falls)
-use of restraints can cause skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration, respiratory difficulties, and even death
using side rails as restraints
-can pose serious risks for a confused or agitated patient
-a person of small stature can asphyxiate by becoming wedged between mattress and bedframe
-most injuries from siderail entrapment are frail, of advanced age, or confused
physical examination for fall risk
Assess:
-mobility status
-ability to communicate
-level of awareness or orientation
-sensory perception
-identify potential safety hazards
-recognize manifestations of domestic violence or neglect
factors that contribute to falls
-lower body weakness
-poor vision
-gait and/or balance issues
-problems with feet and/or shoes
-use of psychoactive medications
-postural dizziness
-hazards in the home
-advanced age
-fear of falling
-chronic conditions (arthritis, diabetes, stroke, Parkinsons, incontinence, dementia)
Safety Considerations for Adolescents
-teach safe driving skills
-teach avoidance or tobacco and alcohol
-emphasize gun safety
-follow healthy lifestyle
-teach about sexuality, STIs, and birth control
-get physical examination before participating in sports
-teach risk of infection with body piercing and tattoos
-teach about guns and violence
-discuss dangers associated with the internet
Why?
-this is a critical period in growth and development
-during this time the mind has a great ability to acquire and use knowledge
-teens peer group is a greater influence than parents
safety considerations for adults
-remind them of effects of stress on lifestyle and health
-enroll in defensive driving course
-evaluate workplace for safety
-counsel about domestic violence
Why?
-visible signs of aging may become apparent
-lifestyle behaviors and situational or family crises can impact an adults overall health and cause stress
-preventative health practices help adults improve the quality and duration of life
safety considerations for older adults
-identify safety hazards in the environment
-modify the environment as necessary
-attend defensive driving courses or courses designed for older drivers
-encourage regular vision and hearing tests
-ensure hearing aids and eyeglasses are available and functioning
-have operational smoke detectors in place
-objective document and report any signs of neglect and abuse
Why?
-accidental injuries occur more frequently in older adults because of decreased sensory abilities, slower reflexes, and reaction times
-collaboration between family and healthcare providers can ensure a safe, comfortable environment and promote healthy aging
incident reporting
-must be completed after any accident or incident in a health care facility that compromises safety
-describes the circumstances of the accident or incident
-details the patient's response to the examination and treatment of patient after the incident
-completed by the nurse immediately after the incident
-it is not a part of the medical record and should not be mentioned in documentation
types of communication
-direct vs. remote
-verbal or non-verbal
-talking or listening
-social communication vs. professional/collaborative
verbal communication
Depends on language or a prescribed way of using words so that people can share information effectively
Ex.
-written
-spoken
-television and radio
-movies
-magazines
-books
-computers
-posters
-brochures
nonverbal communication
Transmission of information without the use of words, it helps nurses to understand subtle and hidden meanings in what the patient is saying
Ex.
-touch
-eye contact
-facial expression
-body posture
-gestures
-physical appearance
-voice tone
-rate of speech
-neatness
-movement
-electronic communication (social media, email and text messages)
channels of communication
Auditory: spoken words and cues
Visual: sight, observations, and perception
Kinesthetic: touch
nurses use all three
SBAR
A hand-off communication method that provides consistent communication that is clear structured, and easy to use. Recommended by the Joint Commission and Institute for Healthcare Improvement in an effort to eliminate breakdowns in communication and potential adverse events.

-Situation
-Background
-Assessment
-Recommendations
Situation
-Who the patient is
-The patients code status
-The problem or reason for conversation
-Vital signs and assessment
-What your concerns are and why
Background
-the patients mental status (agitated, confused, lethargic, non-responsive)
-the condition of the patients skin (warm, dry, pale, mottled, diaphoretic, cold/warm extremities)
-is the patient on oxygen? how many liters? for how long? what is their SPO2?
Assessment
-What you think the problem is
(cardiac, infection, neurological, respiratory)
-You may not be sure of the problem
-does the patient seem unstable and may get worse?
Recommendation
-what you think the physician should do (Upgrade to ICU, come see the patient, talk to patient or family about code status, ask a consultant to see patient now)
-are there any tests needed? (CXR, ABG, EKG, CBC, BMP)
-if there's a change in treatment make sure to ask how often they want vital signs, how long they think the problem will last, what should you do if the patients condition doesn't improve?
objective data
- The "S" and "B"
-observable and measurable data obtained through observations, physical examination, and laboratory and diagnostic testing
subjective data
-the "A" and "R"
-information from your point of view that you have gathered from the patients condition and status
developing listening skills
-sit when communicating with a patient
-be alert and relaxed and take your time
-keep the conversation as natural as possible
-maintain eye contact if appropriate
-use appropriate facial expressions and body gestures
-think before responding the patient
-do not pretend to listen
-listen for themes in the patient's comments
-use silence, therapeutic touch, and humor appropriately
listening attentively is key to productive communication
interviewing techniques
-purpose is to obtain accurate and thorough information
-interviewing is a major tool for collecting data during assessment
-all interviews should begin with an explanation of the purpose of the interview
open-ended questions or comment
-allows patients to express what they understand to be true, yet is specific enough to prevent digressing from the issue at hand
-it encourages free verbalization
-it prevents the patient from giving a simple yes or no that can be limiting
Ex.
-What did your healthcare provider tell you about your need for this hospitalization?
closed question or comment
-provides the receiver with limited choices of possible responses and might ofter be answered by one or two words, "yes" or "no"
-used to gather specific information from a patient and to allow the nurse and patient to focus on a particular area
-can often be a barrier to effective communication
Ex.
-What medicines have you been taking at home?
clarifying question or comment
-clarifying question or comment to gain an understanding of a patients comment
-can prevent possible misconceptions that could lead to an inappropriate nursing diagnosis
-overuse can lead to a patient believing that the nurse is not listening or lacks appropriate knowledge
Ex.
Patient: I have never needed to take medicine before in my life.

Nurse: Is this the first health problem you have had?
validating question or comment
-serves to validate what the nurse believes he or she has heard or observed
-overuse may lead to patient thinking that he or she is not listening
Ex.
- At home, you have been taking both a water pill and a blood pressure pill every day. Did you take them today?
reflective question or comment
-a technique that involves repeating what the person has said or describing the persons feelings
-encourages patient to elaborate on their thoughts and feelings
Ex.
Patient: I've been really upset about my blood pressure and have to take these pills.

Nurse: You've been upset...

Patient: I guess I'm worried about what could happen if my blood pressure gets too bad.
Sequencing question or comment
-used to place events in chronological order or to investigate a possible cause-and-effect relationship between events
Ex.
Patient: I don't feel like myself anymore since I've been taking my blood pressure medicine. I'm tired and don't have any energy.

Nurse: Your tiredness began after you started taking your medicine?
Directing question or comment
-sometimes it is necessary to obtain more information about a topic brought up earlier in the interview or to introduce a new aspect of the current topic
-nurse can gain additional valuable information that aids in assessing patients health status and educational or counseling needs.
Example of a directing question
Nurse: You mentioned your dad earlier. Did he develop complications related to high blood pressure?

Patient: Yes.

Nurse: What sort of complications?

Patient: Kidney failure. He was on dialysis for years before getting a transplant.

Nurse: Are you afraid this might happen to you?
failure to perceive the patient as a human being
-blocks communication
-nurses must focus on the whole patient and not merely diagnosis
-patients should be addressed by a formal name (Mr. Mrs.) rather than slang (honey, sweetie)
failure to listen
-blocks communication
-patients may not feel that they are able to speak freely to their nurse
-dont miss valuable opportunities for important communication by approaching patients with a closed mind or focusing on your own needs rather than the patients
-you must have confidence in your ability to meet the challenges of the patient
nontherapeutic comments and questions
-cliches
-questions requiring only a yes or no answer
-questions containing the word why or how
-questions that probe for information
-leading questions
-comments that give advice
-judgmental comments
changing the subject
-blocks communication
-patient might be at a point of readiness to discuss something and will likely feel frustrated if put off by a change in subject
Ex.
Patient: When can I expect to be told about my insulin?

Nurse: Let's discuss your diet now so that you will know what to eat when you get home. We can discuss your insulin some other time
Giving false assurance
-might give patients the impression that things are going to turn out well even when knowing the chances are not good
-they may also give the impression that the nurse is not interested in their problems
-use of cliches gives a patient false assurances
Gossip and rumor
-can produce detrimental effects on relationships and group building
-could damage the reputation of others
-can cause blocks in team building
disruptive interpersonal behavior and communication
-disruptive behavior has a negative effect on clinical outcomes and interpersonal relationships
-adverse effects occurs when communication between health care professionals is ineffective, abusive, or negative
-must follow a code of conduct defining acceptable, disruptive, and unacceptable behavior
effects of immobility
-decreased muscle tone, size and strength
-decreased joint mobility and flexibility
-limited endurance and activity tolerance
-bone demineralization
-lack of coordination and altered gait
-decreased ventilatory effort and increased respiratory secretions, atelectasis, and respiratory congestion
-increased cardiac workload
-orthostatic hypotension
-venous thrombosis
-impaired circulation and skin breakdown
-urinary stasis
-infection
-altered sleep patterns, pain, depression, anger and anxiety
SPICES Framework
Factors that affect a patients mobility; the presence of these conditions can lead to increased death rates, higher costs, and longer hospitalizations for older clients. These conditions are common, preventable, and signal a need for a more in-depth assessment

-Sleep disruption
-Problems with eating and feeding
-Incontinence
-Confusion
-Evidence of falls
-Skin breakdown
Exercise and Cardiovascular system
-increased efficiency of the heart
-decreased HR and BP
-increased blood flow to all body parts
-improved venous return
-increased circulating fibirnolysin (substance that breaks up small clots)
Exercise and Respiratory system
-improved alveolar ventilation
-decreased work of breathing
-improved diaphragmatic excursion
Exercise and Musculoskeletal system
-increase muscle efficiency (strength) and flexibility
-increased coordination
-reduced bone loss
-increased efficiency of nerve impulse transmission
exercise and metabolic processes
-increased triglyceride breakdown
-increased gastric motility
-increased production of body heat
Exercise and Urinary system
-increases blood circulation which improves blood flow to kidney
-allows kidneys to maintain body fluid balance and acid-base balance more efficiently
Exercise and psychosocial outlook
-increased energy, vitality and general well being
-improved sleep
-improved appearance
-improved self-concept
-increased positive health behaviors
exercise and skin
-increased circulation nourishes skin
physical assessment for mobility
-general ease of movement and gait
-alignment
-joint structure and function
-muscle mass, tone, and strength
-endurance
variable leading to back injury in health care workers
-uncoordinated lifts
-manual lifting and transferring of patients with out assistive devices
-lifting when fatigued or after recent back injury recovery
-repetitive movements such as lifting, transferring, and repositioning patients
-standing for long periods of time
-lifting and transferring patients
-repetitive tasks
-transferring/repositioning uncooperative or confused patients
assessments made prior to moving patient
-check the medical record for any conditions or order limiting mobility
-perform a pain assessment prior to the time for the activity
-if the patient reports pain, administer medication
-assess the patients ability to assist with moving and the need for assistants or equipment
-assess the patients skin for signs of irritation, redness, edema, or blanching
gait belts
-do not use on patients with abdominal or thoracic incisions
-used for transferring patients and assisting with ambulation, providing a firm grasp for the caregiver and facilitating transfer
-belt is placed on patients waist and secured by velcro fasteners
stand-assist and repositioning aids
-patient must be partially dependent, cooperative, with good upper body mobility and strength with bearing capabilities
-help patient to stand
Lateral-assist devices
-reduces patient-surface friction during side-to-side transfers
-roller boards
-transfer boards
-inflatable mattresses(hover mat)
-risk for caregiver injury related to horizontal reach and posture required
friction-reducing sheets
-used for moving patients up in bed, turning or repositioning
-reduces friction and force on patients skin
mechanical lateral-assist devices
-slide patient from stretcher to bed with out lifting
transfer chairs
-chairs that transfer to stretchers
-used for patients who are uncooperative, with inability to bear weight
powered stand-assist and repositioning lift
-used for patients who are cooperative with ability to bear weight
-assists patient to stand with no lifting
-sling is placed around the patients back and under the arms
-the device mechanically assists the patient to stand, with out assistance from nurse
powered full-body lift
-used for patients who are uncooperative with an inability to bear weight
positioning patients in bed
-must maintain correct body alignment that facilitates physiologic functioning
You can use:
-foam wedges and pillows
-matresses that are firm but have give
-adjustable beds
-trapeze bar
-cradles
-trochanter rolls
-hand and wrist splints
-side rails
-foot boards, boots
Passive Range of Motion (ROM)
-exercise performed by nurse with no patient participation
active range of motion
-exercises done independently by patient
-no participation by nurse or others
OSHA guidelines on lifting
-advocates of "no-lift policy"
-recommends use of mechanical lifting devices for moving patients
-do not lift anything heavier than 35 lbs with out assist device
-ensure enough staff is around and available to help
-assess area for clutter and accessibility
-decide which equipment to use
-plan carefully what you will do before moving the patient
safe patient transfer
-assess the patient, know their medical diagnosis, capabilities, and any movements not allowed
-assess patients ability to assist with movement and encourage patients to assist in their own transfers
-assess patients ability to understand instructions and cooperate with staff
use of walkers
-improve balance by increasing patients base of support
-walkers with wheels are best for patients with a gait that is too fast or who have difficult lifting the walker
-these patients do not rely on the walker to bear weight
-can be difficult to maneuver
-the top of the walker should line up with the crease on the inside of the patients wrist when arms are relaxed at patients sides
-when hands are place on the grips the elbows should be flexed about 30 degrees
-the walkers rubber tips should be intact to prevent slipping
Walker use instruction
-wear no-skid shoes or slippers
-use chair arms for support when rising from a seated position, then place one hand at a time on walker
-begin by pushing the walker forward, keeping the back upright, place one leg inside the walker, keeping the walker in place. Then step forward with remaining leg into the walker, keeping the walker still
-caution patient to avoid pushing the walker out too far in front and leaning over it, patients should always step into the walker
-never attempt to used a walker on stairs
use of canes
-widen a persons base of support and improve balance
-they come in three variations, single ended with half circle handles, single ended with straight handles, and tripod or four pronged
-many canes are adjustable
-should fit so that when patient stands with the canes tip 4 inches to the side of the foot
Cane use instruction
1. the patient stands with weight evenly distributed between feet and cane
2. the cane is held on the patients stronger side and is advanced one small stride ahead
3. supporting weight on the stronger leg and the cane, the patient advances weaker foot forward, parallel with the cane
4. supporting weight on the weaker leg and the cane, the patient brings the stronger leg forward to finish the step
single ended canes with half circle handle
-recommended for patients requiring minimal support and those who will be using stairs frequently
single ended canes with straight handle
-recommended for patients with hand weakness because the hand grip is easier to hold
-not recommended for patients with poor balance
Tripod/Quad canes
-provide a wide base of support
-recommended for patients with poor balance
safe administration of medication
Know:
-the drugs being administered
-drug names (generic and brand)
-preparations for administration
-classification of the drug
-dosage
-desired and adverse effects
-physiologic factors that affect drug action
Nursing process and medication administration
Assessment:
-comprehensive medication history, allergies
-Pt's health assessment (vital signs, labs)
-ongoing assessments of pts response to medication
Nursing diagnosis
-based on assessment data
Plan of action
Implementation of plan
Evaluation of intervention or action taken
-outcomes evaluated to assess if actions were effective
-plan of care tailored to the patients needs
oral drug preparations
-capsule
-pill
-tablet
-extended release
-elixir
-suspension
-syrup
Topical drug preparations
-Liniment
-lotion
-ointment
-suppository
-transdermal patch
injectable
Given via a needle
capsule
Powder or gel form of an active drug enclosed in a gelatinous container; may also be called liquigel
elixir
Medication in a clear liquid containing water, alcohol, sweeteners, and flavor
enteric coated
A tablet or pill coated to prevent stomach irritation
extended release
Preparation of a medication that allows for slow and continuous release over a predetermined period; may also be referred to as CR or CRT (controlled release), SR (sustained or slow release), SA (sustained action), LA (long acting), or TR (timed release)
liniment
Medication mixed with alcohol, oil, or soap, which is rubbed on the skin
lotion
Drug particles in a solution for topical use
lozenge
Small oval, round, or oblong preparation containing a drug in a flavored or sweetened base, which dissolves in the mouth and releases the medication; also called troche
ointment
Semisolid preparation containing a drug to be applied externally; also called an unction
pill
Mixture of a powdered drug with a cohesive material; may be round or oval
powder
Single or mixture of finely ground drugs
solution
A drug dissolved in another substance (aqueous solution)
suppository
An easily melted medication preparation in a firm base such as gelatin that is inserted into the body (rectum, vagina, urethra)
suspension
Finely divided, undissolved particles in a liquid medium; should be shaken before use
syrup
medication combined in a water and sugar solution
tablet
Small, solid dose of medication, compressed or molded; may be any color, size, or shape; enteric-coated tablets are coated with a substance that is insoluble in gastric acids to reduce gastric irritation by the drug
transdermal patch
Unit dose of medication applied directly to skin for diffusion through skin and absorption into the bloodstream
generic name
legal noncommercial name for a drug
brand-name drug
a drug with a registered name or trademark
factors affecting absorption of medications
-route of administration
-lipid solubility
-pH
-blood flow
-local conditions at the site of administration
-drug dosage
route of administration
-the rate of absorption depends on the route the drug is taken
-oral preparations usually take the longest to be absorbed
-IM and SubQ are more rapid
-IV drugs have the fastest rate of absorption
lipid solubility
-cell membranes have a fatty acid layer
-a drug that is more lipid soluble can be absorbed more readily and pass more easily through the cell membrane
pH
-acidic drugs are well absorbed in the stomach
-drugs that are basic remain ionized or insoluble in an acid environment
Blood flow
-absorption is increased with blood flow
-patients with impaired circulatory function absorb drugs less rapidly than do patients with normal circulatory function
local conditions at the site of administration
-the more extensive the absorbing surface, the greater the absorption and the more rapid the effect
-ex, pt with burns will would have poor absorption from an IM injection because of damage of blood supply
-fatty food slows the rate of gastric emptying, which can slow rate of absorption
-other foods may enhance rate of absorption
drug dosage
-the amount of a drug administered directly impacts its bioavailability
-ex, loading dose
allergic effects
-adverse effect
-anaphylactic reaction
-immune response that occurs when the body interprets an administered drug as a foreign substance and forms antibodies against the drug
drug tolerance
-adverse effect
-occurs when the body becomes accustomed to the effects of a particular drug over a period of time
-larger doses of the drug must be taken to produce desired effect
toxic effect
-adverse effects
-groups of symptoms related to drug therapy that carry risk for permanent damage or death
idiosyncratic effect
-adverse effect
-any usual response to a drug that may manifest itself by over response, under-response, or even the opposite of the expected response
drug interactions
-adverse effect
-occur when one drug is affected in some way by another drug, a food, or another substance that is taken at the same time
therapeutic range
-concentration of drug in the blood serum that produces the desired effect with out causing toxicity
peak level
The maximum concentration of a drug in the body after administration, usually measured in a blood sample for therapeutic drug monitoring.
trough level
the point when the drug is at its lowest concentrations, indicating the rate of elimination
half-life
-amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body
standing order
-routine order that is carried out until it is cancelled by another order
PRN
as needed
single or one time order
carried out only once, at a time specified by the prescriber
STAT order
single order carried out immediately
parts of the medication order
-patients name
-date and time order is written
-name of drug to be administered
-dosage of drug
-route by which drug is to be administered
-frequency of administration
-signature of the person writing the order
medication supply systems
-stock supply
-individual unit dose supply
-medication cart
-computerized automated dispensing system
-bar code-enabled medication cart (BCMA)
Computerized automated dispensing system
-technology based on stock supply of unit dose medications
-large cabinet is used containing stock medications
-system can be accessed with username and password or fingerprint
Unit dose supply
-self-contained packet that holds one tablet or capsule
-each patient is supplied with the medication needed for a period of time
medication cart
-cart with meds for multiple patients all in different drawers
-a computer is usually on top of the cart to access the patients medical records
bar-code medication administration
-computerized bar coded administration system
-each patient and each nurse is identified by a bar code
-each drug is also packaged with a bar code to identify the form and dosage
-confirms patient and meds and reduces room for error
-alerts nurse to discrepancies
Three checks of drug administration
1. when the nurse reaches for the unit dose package or container
2. after retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multi dose container
3. before giving the unit dose medication to the patient, or when replacing the multi dose container in the drawer or shelf
rights of administration
Right:
-medication
-patient
-dosage
-route
-time
-reason
-data
-response
-documentation
-to education
-to refuse
medication errors
-check patients condition immediately
-notify nurse manager and primary care provider
-write description or error and remedial steps taken on medical record
-complete form used for reporting errors, as dictated by facility policy (special event, event, unusual occurrence report)
handeling controlled substances
-all medication systems should be locked
-sometimes controlled substances are in a double locked system
-a record must be kept for each narcotic that is administered
Required information:
-name of patient
-amount of substance used
-hour the controlled substance was given
-name of the prescribing provider
-name of the nurse who administered the substance
Maintaining a safe environment
-good lighting
-work alone when prepping meds
-dont leave meds unattended
-lock meds
- lock cart
- prepper must also be the administrator
-dont administer meds if you are distracted or interrupted
types of medication errors
-Inappropriate prescribing of the drug
-Extra, omitted, or wrong doses
-Administration of drug to wrong patient
-Administration of drug by wrong route or rate
-Failure to give medication within prescribed time
-Incorrect preparation of a drug
-Improper technique when administering drug
-Giving a drug that has deteriorated
criteria for choosing equipment for injections
-route of administration
-viscosity of the solution
-quantity to be administered
-body size
-type of medication
Parts of needle and syringe
touch only outside of syringe barrel and handle of plunger (sterile)

avoid letting unsterile object touch tip or inside of barrel, hub, shaft of plunger, or needle
Angles of Insertion for Various Injections
--IM 72, 90°.
--SQ 45, 90°.
--Intradermal 5-15°.
intradermal injection
-administered into the dermis, just below the epidermis
-has the longest absorption time
-sites: inner surface of forearm, upper back, and under scapula
-A 1/4″ to 1/2″, 25- or 27-gauge needle is used and the angle of administration is 5 to 15 degrees.
-dosage is usually small <0.5mL
SubQ injection
-45 degrees, 2cc 25g
-administered into the adipose tissue layer just below the epidermis and dermis
-Sites: outer aspects of the upper arm, abdomen, anterior thigh, upper back, upper ventral or dorsogluteal area
injection route of administration
-a longer needle is required for IM compared to intradermal or SubQ
viscosity of the solution
some medications are more viscous than others and require a large lumen needle to inject the drug
quantity to be administered
the larger the amount of med to be injected, the greater the capacity of the syringe
body size
an obese person requires longer needles to reach the muscle than does a thin person.
type of medication
there are special syringes for certain uses.
ex. insulin syringe is only used for insulin
infection cycle
Infectious agent, reservoir, portal of exit, means of transmission, portal of entry and susceptible host.
infectious agents
-Bacteria: most significant and most prevalent in hospital settings
-Virus: smallest of all microorganisms
-Fungi: plant-like organisms present in air, soil, and water
reservoirs for microorganisms
-other people
-animals
-soil
-food, water, milk
-inanimate objects
common portals of exit
-respiratory
-GI
-Genitourinary tracts
-breaks in skin
-blood and tissue
incubation period
-organisms growing and multiplying
prodromal stage
-person is most infectious
-vague and non-specific signs of disease
full stage of illness
-presence of specific signs and symptoms of disease
convalescent period
-recovery from the infection
factors affecting host susceptibility
-intact skin and mucous membranes
-normal pH levels
-WBC count
-Age, sex, race, hereditary factors
-immunizations (natural or acquired)
-fatigue
-climate
-nutritional and general health status
-stress
-use of invasive or indwelling medical devices
signs of acute infection
-redness
-heat
-swelling
-pain
-loss of function
Lab data indicating infection
-elevated WBC count (normal range 5,000-10,000/mm^3)
-increased specific types of WBCs
-elevated erythrocyte sedimentation rate
-presence of pathogen in urine, blood, sputum, or draining cultures
Body's defense against infection
-Skin and mucous membranes (first line defense)
-Body's normal flora (first line defense)
-Inflammatory response (helps neutralize and control or eliminate the offending agent)
-Immune response
Use of PPE
The last line of defense against occupational hazards/infectious agents:
-gloves
-mask
-gown
-eyewear
Standard precautions
-CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions
-these precautions apply to blood, all body fluids, secretions, secretions except sweat, non intact skin, and mucous membranes
-respiratory hygiene/cough etiquette
-safe injection practices
transmission-based precautions
-CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions
Three types:
-airborne
-droplet
-contact
Airborne precautions
-used for infections that spread through air (ex. tuberculosis, varicella)
-must be in a negative pressure room
-must wear respirator
-transport patient out of room only when necessary and place surgical mask on them if possible
-consults CDC guidelines
Droplet precautions
-used for infections that are spread by large-particle droplets (rubella, mumps, diphtheria, adenovirus, flu)
-use a private room
-wear PPE
-transport patient only when necessary, have them wear surgical mask if possible
-visitors remain 3ft from infected person
Contact precautions
-used for patients who are infected or colonized by a multi-drug resistant organism (MDRO)
-place in private room
-wear PPE
-limit movement of pt out of the room
-avoid sharing patient-care equipment
medical asepsis
-practices designed to reduce the number and transfer of pathogens; synonym for clean technique
Surgical asepsis
-sterile technique
-used in operating room, labor and delivery areas and certain diagnostic testing areas
-can be performed at patient beside with insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine
medical asepsis at home
-wash hands before preparing or eating food
-prepare foods at high enough temperatures
-use care with cutting boards and utensils
-keep food refrigerated
-wash raw fruits and veggies
-use pasteurized milk and fruit juices
-wash hands after using bathroom
-use individual care items
categories of pain
-duration (acute/chronic)
-localization/location
-Etiology
Acute pain
-rapid in onset
-varies in intensity and duration
-protective in nature
Chronic pain
-may be limited, intermittent, or persistent
-lasts beyond the normal healing period
-periods of remission or exacerbation are common
origin of pain
-Physical: cause of pain can be identified
-Psychogenic: cause of pain cannot be identified
-Referred: pain is perceived in an area distant from its point of origin (usually with internal organs)
factors that affect the pain experience
-culture
-ethnic variables
-family
-sex
-gender
-age
-support
-environment
-anxiety and fear
-previous pain experiences
general assessment of pain
-patients verbalization and description
-duration
-location
-quantity/intensity
-quality
-chronology
-aggravating and alleviating factors
-physiologic indicators
-behavioral responses
-effects of pain on activities and lifestyle
basic methods of assessing pain
-patient self-report
-identify pathologic conditions or procedures that may be causing pain; consider physiologic measures
-report of family member or other close person
-nonverbal behaviors(restlessness, grimacing, crying, clenching fists, protecting painful area)
-physiologic measures (increased BP and HR)
-attempt an analgesic trial and monitor results
Pain assessment tools
-Wong-Baker FACES
-Beyer Oucher pain scale
-CRIES pain scale
-FLACC scale
-COMFORT scale
Wong-Baker FACES
-pain rating scale asks children to compare their pain to a series of faces ranging from a broad smile to a tearful grimace
-Adults and children >3 in all patient care settings
Beyer Oucher pain scale
-For use in young patients, combines a 0-to-100 scale with six photographic images of children in pain. This scale is helpful for use with older children. Adaptations of the Oucher pain scale are also available for various ethnic groups.
CRIES pain scale
Neonates (ages 0-6 months)
FLACC scale
-Faces
-Legs
-Activity
-Cry
-Consolability
-for infants 2 months to 7 years who are unable to validate the presence of or quantity the severity of the pain
COMFORT scale
infants, children, adults who are unable to use NRS or Wong Baker FACES pain rating scale
Nursing interventions for pain
-establishing trusting nurse-patient relationship
-manipulating factors affecting pain experience
-initiating nonpharmacologic interventions
-reviewing additional pain control measures
-considering ethical and legal responsibility to relieve pain
-teaching patient about pain
Nonpharmacologic Pain Management
-distraction
-humor
-music
-imagery
-relaxation
-cutaneous stimulation
-acupuncture
-hypnosis
-biofeedback
-therapeutic touch
-animal-facilitated therapy
somatic pain
Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves.
cutaneous pain
superficial pain usually involving the skin or subcutaneous tissue
visceral pain
a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera
referred pain
pain that originates in one part of the body and is perceived in an area distant to that part.
Bereavement
includes both grief and mourning (the outward display of loss) as the individual deals
with the death of a significant individual in his life.
Necessary Loss
This is a loss related to a change that is part of the cycle of life that is anticipated but still may be intensely felt. This type of loss can be replaced by something different or better.
Actual Loss
This is any loss of a valued person, item, or status, such as loss of a job.
Perceived Loss
This is any loss defined by the client that is not obvious or verifiable to others.
Maturational or Developmental Loss
This is any loss normally expected due to the developmental processing of life. These losses are associated with normal life transitions and help to develop coping skills.
Situational loss
This is any unanticipated loss caused by an external event.
5 Stages of Grief
Denial, anger, bargaining, depression, acceptance
When should some acceptance be noticed in normal grief?
In 6 months
Disenfranchised Grief
This grief entails an experienced loss that cannot be publicly shared or is not
socially acceptable, such as suicide.
When are medications are given with palliative care?
Given for air hunger, anxiety, and pain
When can the law require an autopsy?
In a homicide, suicide, accidental death, or within 24 hours of hospital admission.
Hydrocolloid Dressing
An occlusive dressing that swells in the presence of exudate; composed of gelatin
and pectin, it forms a seal at the wound's surface to prevent evaporation of moisture from the skin
Hydrogel (Aquasorb)
Hydrogel (Aquasorb) - Composition is mostly water; gels after contact with exudate, promoting
autolytic debridement and cooling
Stage 1 pressure ulcer
Intact skin with an area of persistent, nonblanchable redness. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
Stage 2 pressure ulcer
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible
and superficial. Edema persists, and the
ulcer may become infected, possibly with pain and scant drainage.
Stage 3 pressure ulcer
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer
may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
Stage 4 pressure ulcer
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,
bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
Unstageable pressure ulcer
No determination of stage because eschar or slough obscures the wound
What risk assessment scales are used for pressure ulcers?
Braden, Norton
How often should you reposition a client while sitting in a chair?
Every hour
What kind of moisture barrier should you use on patients that are incontinent?
dimethicone-based or alcohol free. Do not use baby powder because of the grit
Interventions for a stage 2 pressure ulcer
Maintain a moist healing environment
(saline or occlusive dressing).
Promote natural healing while
preventing the formation of scar tissue
Interventions for a stage 3 pressure ulcer
Clean and/or debride:
Prescribed dressing.
Surgical intervention.
Proteolytic enzymes.
Interventions for a stage 4 pressure ulcer
Prescribed dressing.
Surgical intervention.
Proteolytic enzymes.
Perform nonadherent dressing
changes every 12 hr.
Treatment may include skin grafts or
specialized therapy such as hyperbaric oxygen
What type of healing intention is a stage 3 pressure ulcer, and a burn?
secondary intention
What is a "legally blind" vision?
20/200
age-related loss of the eye's ability to focus on close objects
Presbyopia
Cataracts
opacity of lense
With glaucoma you lose what type of vision?
loss of peripheral vision
With Macular Degeneration you lose what type of vision?
Loss of central vision
What can you see with the ophthalmoscope?
allows visualization of the back part of the eyeball (fundus), including the retina,
optic disc, macula, and blood vessels.
What are the names of the visual acuity tests?
Snellen and Rosenbaum eye charts.
What does tonometry measure?
Intraocular pressure
What is the expected range of intraocular pressure?
10-21 mmHg
With what condition is intraocular pressure elevated?
elevated with glaucoma, especially angle-closure glaucoma.
What does gonioscopy allow visualization of?
the iridocorneal angle or anterior chamber of the eyes
What does Slit lamp allows visualization of?
the anterior portion of the eye, such as the cornea, anterior chamber, and the lens.
An alteration in the middle ear that blocks sound waves before they reach the inner ear.
Conductive hearing loss
an alteration in the inner ear that involves cranial nerve VIII or cochlear damage.
Sensorineural hearing loss
presbycusis
decreased ability to hear high-pitched sounds
Patient's with conductive hearing loss hear better in what kind of environments?
loud
What would a Rinne test look like for a pt with conductive hearing loss?
demonstrates that air conduction of sound is less than or equal to bone conduction (AC < or = to BC)
What would a Weber test show with a pt with conductive hearing loss?
Weber test that lateralizes to the affected ear
What would a Rinne test look like for a pt with sensorineural hearing loss?
demonstrates expected response of air conduction is greater than bone conduction
(AC > BC), but length of time is decreased for both
What would a Weber test show for a pt with sensorineural hearing loss?
Weber test that lateralizes to unaffected ear
mydriasis
dilation of the pupil
What does an otoscope show?
An otoscope allows visualization of the external auditory canal, the tympanic membrane (TM),
and malleus bone visible through the TM
What should the TM look like?
The tympanic membrane should be pearly gray and intact. It should provide complete
structural separation of the outer and middle ear structures
Where should the light reflex be visible on the TM?
The light reflex should be visible from the center of the TM anteriorly (5 o'clock right ear;
7 o'clock left ear).
How often do you need to get a new rx for restraints on an adult?
Every 4 hours
How often do you need to get a new rx for restraints on a pt aged 9-17 years old?
every 2 hours
How often do you need to get a new rx for restraints on a pt younger than 9 years old?
Every hour
What is the maximum time of consecutive hours you can use restraints?
24 hours
How much room do you need to leave between the restraint and the patient?
2 fingers
When opening a sterile pack, you should open the first flap which direction?
Away from your body
When pouring solution into a cup on the sterile field, how should you hold the solution?
With your hand over the label
What are three medications that change the urine color?
Phenazopyridine, amitriptyline, levodopa
What color does amitriptyline turn your urine?
Blue/green
What color does levodopa turn your urine?
Brown/black
How much urine output is the bare minimum and the physician should be called for?
30ml/hr for 2 consecutive hours
How often should you clean a urinary catheter?
At least 3 times a day and after defecation
Class of oxybutynine
Urinary antispasmodic
Oxybutynine contraindications
glaucoma
Oxybutynine side effects
Increased intraocular pressure, dizziness, tachycardia, constipation
phenazopyridine class
bladder analgesic
Phenazopyridine contraindications
hepatic disorders and renal insufficiency
How should you take phenazopyridine?
with food
What post void residual must you have to not have a catheter?
Less than 50 ml
Delirium
Acute, temporary, and usually relates to other psychologic conditions.
How often should you remove abdominal binders?
Every 2 hours
How often should you encourage active or do passive ROM?
2-3 times a day
Where should you hold the cane?
On the strong side of the body
How far should you move the cane in front of you when walking?
6-10 inches
How should your crutches be positioned when sitting or rising from a chair?
Place on the unaffected side
If a patient is using an ice/heat therapy, how often should you assess the site?
Every 5-10 minutes
How often should you remove ted hose?
2 times a day
How long does the inflammatory stage of healing last?
3-6 days
How long does the proliferative stage of healing last?
3-24 days
Which stage of sleep is also called Delta sleep?
Stage 4
Which stage of sleep is the deepest sleep?
NREM stage 4
What condition is characterized by more than five breathing cessations lasting longer than 10 seconds per hour during sleep, resulting in decreased arterial oxygen saturation levels.
Sleep apnea
___________ refers to how medications run through the body
pharmacokinetics
____________ is the transmission of medications from the location of administration (gastrointestinal tract, muscle, skin, or subcutaneous tissue) to the bloodstream.
Absorption
_________ is the transportation of medications to sites of action by bodily fluids.
Distribution
What must be present in order for medications to pass through the blood brain barrier and placenta?
They must be lipid soluble or have a transport system
____________ changes medications into less active forms or inactive forms by the action of enzymes.
Metabolism (biotransformation)
When are trough levels drawn?
Immediately before the next dose of medication
Describes the interactions between medications and target cells, body systems, and organs to produce effects.
Pharmacodynamics
How much water should you flush through the NG before and after meds?
15-30 mLs
How much water should you mix meds with when preparing to give through NG tube?
15-30mLs
What happens during ventricular systole?
the ventricles force blood into the aorta, it represents the maximum amount of pressure exerted on the arteries
What happens during ventricular diastole?
The ventricles relax and there is minimal pressure on the arteries
What is the acceptable oral temperature range?
36-38 degrees celsius; 96.8-100.4 degrees farenheit
Transfer of heat from the body directly to another surface (when the body is immersed in water)
Conduction
Dispersion of heat by air currents (wind blowing across exposed skin)
Convection
Dispersion of heat through water vapor (sweating)
Evaporation
Transfer of heat from one object to another without the objects touching each other
radiation
How far should you insert a thermometer when getting a rectal temperature?
1-1.5 inches
How do you take a temporal temperature?
Scan the probe across the forehead, over the temporal artery, and then touch the skin behind the earlobe
Hypothermia is a body temperature below
35 degrees celsius
0 grade pulse means
the pulse is absent
1+ pulse means
diminished, weaker than expected
2+ pulse means
Brisk, expected
3+ pulse means
Increased, strong
4+ pulse means
full volume, bounding
What is a pulse deficit?
the difference between the apical pulse and the radial pulse
What is the expected pulse rate for an infant?
120-160
What is the average pulse rate for a 12-14 year old
80-90
The exchange of oxygen and carbon dioxide in the lungs.
Ventilation
The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells.
Diffusion
How do you measure ventilation?
Respiratory rate, rhythm, and depth
How do you measure diffusion?
pulse ox
The flow of blood to and from the pulmonary capillaries
Perfusion
How do you measure perfusion?
pulse ox
What is a regular respiratory rate for a newborn?
30-60
What is regular respiratory rate for a school age child?
20-30
What four things determine cardiac output?
Heart rate, contractility, blood volume, venous return
Systemic vascular resistance
Reflects the amount of restriction or dilation of the arteries
Increased SVR would do what to blood pressure?
Increase it
What is a normal blood pressure?
<120/<80
What is considered pre hypertension?
120-139/80-89
What is considered stage 1 hypertension?
140-159/90-99
What is considered stage 2 hypertension?
>=160/>=100
How long should you wait between lying, sitting, and standing, when taking orthostatic vital signs?
1-3 minutes
What is significant, and considered orthostatic hypotension?
If the systolic blood pressure decreases more than 20mmHG and/or the diastolic pressure decreases more than 10mmHg with a 10-20% increase in heart rate.
How big should the blood pressure cuff be?
40% of the arm circumference where it is wrapped
How big should the bladder of a BP cuff be?
80% the circumference of the arm of an adult and the whole arm of a child
What are the indications for NG tube?
Decompression, feeding, lavage, compression
How do you check placement of an NG tube?
Aspirate content and check pH (ph should be 4)
X-Ray
If the NG tube is not in the correct place, how do you proceed?
Advance it 5cm and recheck
What enteral formula is nutritionally complete?
Polymeric
What type of enteric formula would you give primarily for Patients with hepatic failure, respiratory disease, or HIV
Specialty enteric formula
At what temperature should enteral solutions be before giving?
Room temperature
What should you do before and after each feeding?
Flush the tubing with >=30mL of tap water
When should the provider be notified of residual with enteral feedings?
When the residual is >250mL for 2 consecutive assessments
When should you withhold an enteral feeding and call MD?
Gastric residual >250ml x2 assessments, diarrhea, N/V, Aspiration
A nurse is caring for a client that has been prescribed potassium. The client says the pill is too large and refuses to take it. The nurse offers to break it into two smaller pieces. The nurse is demonstrating which ethical principle?
A. Autonomy
B. Beneficence
C. Justice
D. Nonmalificence
B- Beneficence
If a nurse suspects the client has a fecal impaction, what is the most important question to ask?
A. What types of food have you been eating?
B. Have you been taking stool softeners or laxatives?
C. Have you been able to pass gas?
D. Have you had small, liquid stools?
D- Have you had small, liquid stools. This is a symptom of a fecal impaction because some stool can seep around the impacted stool.
Airborne, droplet, contact precautions LOOK UP
...
How do you perform the romberg test, and what is it looking for?
Have the client stand with their feet together and arms at their sides. It measures stability with and without eyes closed.
How often should a patient change the ostomy appliance?
Once or twice a week
What should you expect stools to look like after a sigmoidoscopy?
Solid and formed
What types of food (high in what electrolyte) should patients with chronic kidney disease avoid?
Potassium such as cantaloupe, banana, and baked potato
If a client with CHF has gained 2kg in 24 hours, you would suspect they have retained how much fluid?
2,000 mLs
A nurse is contributing to the plan of care of a client who is on droplet precautions. The nurse should recommend which of the following for the plan of care?
A. place client in a negative pressure room
B. wear a gown when giving pt medication
C. Remove PPE immediately after exiting client's room
D. Wear a mask while taking clients vital signs
D- you should wear a mask whenever you are within 3 feet of the pt.
What oxygen mask delivers the highest concentration of oxygen?
A non rebreather mask
What hand hygiene should a nurse use after caring for a client with C-Diff
Mild soap hand washing
A nurse is repositioning a quadriplegic client that is laying in supine position. which of the follow is appropriate?
A. Support the clients head with a pillow that maintains cervical flexion
B. Position the clients shoulders off of the pillow for internal rotation
C. place the clients arms at his sides with the elbows extended
D. Internally rotate the clients hips by using a trochanter roll
D- CORRECT: Because you want to prevent external rotation of the hips

A-INCORRECT: You should use a pillow that does not cause cervical flexion
B- INCORRECT: You should use a pillow or blanket to supper the shoulders and prevent internal rotation
C- INCORRECT: The elbows should be in flexed position on pillows when the client is supine
Need to know in Patient Safety
Developmental levels
Mobility, sensory, and cognitive status
Lifestyle choices
Special risks found in health care setting
Patient Safety according to QSEN
Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Patient Safety according to IOM
New standard for quality care—care that is free of unintended injury from acts of commission or omission, in any setting in which it is delivered.
The Joint Commission 2011 National Patient Safety Goals for Hospitals
• Identify patients correctly.
• Use at least two patient identifiers.
• Eliminate transfusion errors.
• Improve staff communication.
• Report important test results in a timely manner.
• Use medicines safely.
• Label medications.
• Reduce harm to patients who take anticoagulation therapy.
• Reduce the risk of health care-associated infections.
• Meet hand hygiene guidelines.
• Prevent multidrug-resistant organism infections.
• Prevent central line-associated bloodstream infections.
• Use safe practices to treat the part of the body where surgery was performed.
• Check patient medicines.
• Identify current medicines and make sure that it is okay for patients to take any new medicines with current medicines.
• Give a list of patient's medicines to the next provider before discharge.
• Give a list of patient's medicines to patient and family before discharge; explain the list.
• Identify patient safety risks.
• Identify individuals at risk for suicide.
Patient Centered Care according to QSEN
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.
Purpose of the National Patient Safety Goals (NPSG) (TJC website)
The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
Error Defined
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
Aims to Improve Quality of Care
- Safe: avoid injuries
- Effective: provide care based on scientific knowledge
- Patient centered: patient values guide all decisions
- Timely: reduce wait and delays
- Efficient: avoid waste of equipment, supplies, ideas, and energy
- Equitable: care does not vary in quality (gender, ethnicity, geographic -location, socioeconomic status)
Risks for Infant, Toddler, and Preschooler
Injuries, lead poisoning, accidents due to particular stage of growth--such as oral activity and children possibly ingesting dangerous substances or choking
Risks for the School-Age Child
Different environments outside of the home, such as school, school transportation, after school activities, etc. Strangers, sports activities, bicycle related injuries.
Risks for the Adolescent
greater independence and separate emotionally from family; tension associated with physical and psychological changes and peer pressures can lead to risk-taking behaviors like smoking or drugs; motor vehicle accidents
Risks for the Adult
lifestyle habits: alcohol/drug use, and smoking; stress leading to accidents or illnesses, such as headaches, gastrointestinal disorders, and infections
Risks for the Older Adult
physiological changes leading to greater fall risk and other types of accidents such as burns and car accidents
Risks within the Healthcare Setting
Medical errors: medication errors, infection, bed sores, and failure to diagnose and treat in time
Chemical use
Falls
Patient-inherent accidents
Procedure-related accidents
Equipment-related accidents
Individual Risk Factors Related to Safety
- Lifestyle
- Impaired mobility
- Sensory or communication impairment
- Lack of safety awareness
Inflammation
A protective reaction;
Can be caused by nonliving agents i.e. heat, trauma;
Always present with infection;
Infection occurs only through superimposed evasion of microorganisms;
It establishes an environment for healing
Infection
Involves invasion of tissue or cells by microorganisms (bacteria, fungi, or viruses)
Always has inflammation present
Often reveals altered lab values ( i.e. WBCs, positive cultures)
Most Frequent Type of Health Care-associated Infections (HAIs)
Catheter-Associated Urinary Tract Infection (CAUTI). Represents as much as 80 percent of HAIs in hospitals.
Iatrogenic Infection
A type of HAI from a diagnostic or therapeutic procedure.
Exogenous Infection
Comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Asperigillus. Do not exist as normal floras.
Endogenous Infection
Occurs when part of the patient's flora becomes altered and an overgrowth results. (staphylococci, enterococci, yeasts, and streptococci) Often happens when a patient receives broad-spectrum antibiotics that alter the normal floras.
Infection and Inflammation
can be local, systemic, acute or chronic
Medical Asepsis
-"Clean" technique.
-Reduces presence of microorganisms.
-Prevents spread from place to person or person to person
Surgical Asepsis
-"Sterile" technique.
-Eliminates all microorganisms, pathogens, spores.
-Requires sterile field and equipment (O.R. and during invasive procedure)
Acute Inflammation
*heals in 2-3 wks
*no residual damage
*neutrophils predominant
(Subacute is basically the same but last longer i.e. endocarditis)
Chronic Inflammation
*lasts for weeks, months or years
*persistence = injured tissues
*predominant cells are lymphs, macrophages
*debilitation leads to decreased immunity
(i.e. rheumatoid arthritis, TB)
Recognizing Infection
Local or systemic
Patient information, clinical appearance (objective and subjective)
Vital signs
Lab values
CBC (Complete Blood Count)
Culture reports
Recognizing Inflammation
Swelling
Redness--Hyperemia
Heat
Pain/Tenderness
Loss of Function
Functions of red blood cells (erythrocytes)
carry oxygen from the lungs to body tissues and transfer carbon dioxide from the tissues to the lungs. Oxygen transfer is accomplished via the hemoglobin contained in RBC's. Hemoglobin combines readily with oxygen and carbon dioxide.
Normal values white blood cells (leukocytes)
normally 5000 to 10,000/microliter, can rise up to 15,000 to 20,000/microliter and higher during inflammation, high white blood cell count can indicate infection
Functions of white blood cells
involved in cellular response of inflammation upon arrival at site; WBC pass through blood vessels and into the tissues; through phagocytosis, neutrophils and monocytes ingest and destroy microorganisms and other small particles
High red blood cell count (polycethemia)
increases in the RBC count occur at high altitudes because less atmospheric weight pushes air into the lungs, causing a decrease in the partial pressure of oxygen and hypoxia. With strenuous physical training, increased muscle mass demands more oxygen.
Normal values of red blood cells
4 to 6 million/microliter
Low red blood cell count (anemia)
can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. Red blood cells live for approximately four months in the bloodstream
Normal levels of platelets
150,000 to 400,000/microliter
Functions of platelets (thrombocytes)
prevent bleeding
Chain of Infection
Infection occurs in a cycle that depends on the presence of:
Infectious agent or pathogen, Reservoir or source for pathogen growth, portal of exit from the reservoir, mode of transmission, portal of entry to a host, susceptible host
Infectious agent
microorganisms include bacteria, viruses, fungi, and protozoa; can cause disease when there is sufficient number, adequate virulence, ability to enter and survive the host, and susceptibility of the host
Reservoir
place where a pathogen can survive but may not multiply, may be in food, oxygen, and water; factors that affect bacteria growth are temperature, pH, and light (organisms can thrive in the dark)
Portal of Exit
for microorganisms to grow and multiply they must exit their host, portals of exits include blood, skin, and mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
Modes of Transmission
the specific way a disease is transmitted, most common: (unwashed hands) direct (person-person), physical contact, indirect (susceptible host to inanimate object), droplet (large particles that travel up to 3 ft), airborne, vehicles, vector (mosquitos)
Portal of Entry
organism enter the body through the same routes they use for exiting
Susceptible Host
depends on the individual degree of resistance to a pathogen (immune response). Factors that influence susceptibility are age, nutritional status, presence of chronic disease, trauma, and smoking
pathogenicity
the ability of a pathogen to produce an infectious disease in an organism
localized infection
localized symptoms (wound infection) pain and tenderness and redness at the wound site
systemic infection
infection that affects the entire body instead of just a single organ or part, can become fatal if left untreated
inflammatory response
protective reaction that serves to neutralize pathogens and repair body cells
nursing actions that control or eliminate infections in the clinical setting
properly administering antibiotics, monitoring response to drug therapy, and using proper hand hygiene and standard precautions; supportive therapy would include proper nutrition and rest
Role of nurse in infection control
Assess patient's defense mechanisms: age, nutritional status, stress, disease process; susceptibility and knowledge of infections;
"Risk for Infection": lab data and clinical appearance;
Consult Infection Control Practitioner: clients with infection
Nursing Care Infection Control-wound care
Handwashing
Use gloves
Elevate foot
Aseptic technique for dressing change
Discard contaminated dressing, linens, etc. properly
Administer medications
Management of fever
Rest
Maintain glucose within normal range
Healthy diet
Teach infection control
Acute/Transient Pain
-Is protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response.
-It eventually resolves, with or without treatment, after an injured area heals.
-Because acute pain has a predictable ending (healing) and an identifiable cause, health team members are usually willing to treat it aggressively.
-Unrelieved acute pain can progress to chronic pain.
Chronic/Persistent Pain (Non-Cancer Pain)
-Is not protective and serves no purpose, lasts longer than 6 months and is constant or recurring with a mild-to-severe intensity.
-Does not always have an identifiable cause, and leads to great personal suffering.
-Chronic pain is a major cause of psychological and physical disability, leading to problems such as job loss, inability to perform simple daily activities, sexual dysfunction, and social isolation.
Chronic/Episodic
pain that occurs sporadically over an extended duration of time, may last for hours, days, or weeks (migraine headaches)
Cancer pain
can be acute and/or chronic, sometimes nociceptive and/or neuropathic; usually due to tumor progression and its related pathological process, invasive procedures, toxicities or treatments, infection , and physical limitation--at actual site or referred
Inferred pain by pathological process
Nociceptive pain--somatic and visceral and neuropathic pain
Nociceptive Pain
Damage to bone, soft tissue, or internal organs
Usually responsive to nonopioids and/or opioids
Types of nociceptive pain: somatic pain and visceral pain
Somatic Pain
Arises from bone, joint, muscle, skin or connective tissue
Usually aching or throbbing in quality and is well localized
Visceral Pain
Arises from viscera, such as the GI tract and pancreas;
Described as squeezing, cramping pain, shooting;
May be due to obstruction of hollow viscous, which causes the cramping and poorly localized pain
Neuropathic Pain
Arises from abnormal or damaged pain nerves. Abnormal processing of sensory input by the peripheral or central nervous system;
Treatment usually includes adjuvant drugs;
A physical cause for reports of excruciating pain may not be evident on examination
Idiopathic Pain
chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
Factors That Influence Pain
Physiological factor: age, fatigue, genes, neurological function;
Social factors: attention, previous experience, family and social support; Spiritual factors;
Psychological factors: anxiety, coping style;
Cultural Factors: meaning of pain, acceptable pain expression
Pain Assessment
Factors influencing the pain experience:
Location
Intensity
Quality
Pattern
Aggravating/relieving factors
Medication history
Pharmacological Measures Nursing Responsibilities (pain management)
Assess pain
Determine when to administer analgesics
Select the appropriate analgesic
Evaluate effectiveness of analgesics
Monitor and manage medication side effects
Suggest changes
Consider the needs of special populations (mentally ill, cognitively impaired, etc)
nursing role in pain management
Direct clinical care
Patient/family teaching
Education of colleagues
Identify system barriers
Medication Administration: Patient Assessment
Identify high-risk patients:
-Liver and kidney impairment
-Genetic factors
-Drug allergies
-Pregnancy
-Elderly and pediatrics
-Tools: patient history, physical exam, and lab results
Medication Administration: Drug Assessment
A complete, legal order:
-Appropriateness (rationale for use of this drug for this patient)
-Action, dosage, route, adverse effects
-Contraindications, interactions
-Other data: lab results, vital signs, etc
Medication Administration: Delivery System
Drug administration and security:
-Drug handling
-Dosage measuring
-Obtaining the drug
-Systems used to dispense the drug
-How to document drug therapy on the MAR (medication administration record)
Six Rights of Medication Administration
Right:
-Patient - 2 identifiers!
-Drug
-Dose
-Route
-Time
-Right documentation
...right to refuse
Evaluation of Drug Effects
-Therapeutic response
-Adverse effect (includes side effects)
-Interactive effects
-Further teaching needs
nursing assessment
deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
steps of the nursing assessment
1) collection and verification of data from a primary source, and secondary sources
2) the analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care
database
built during assessment, concerns the client's perceived needs, health problems, and responses to these problems
sources of data
client, family and significant others, health care team medical records, nurse's experience, other records and literature
subjective data
client's verbal description of their health problems, will include feelings perceptions, and self-report of symptoms
objective data
observations or measurements of a client's health status
nursing health history
data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
data analysis
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.
medical diagnosis
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures
nursing diagnosis
clinical judgment about individual, family, or community responses to actual & potential health problems or life processes; statement describing the client's actual or potential response to a health problem that nurse is licensed and competent to treat.
collaborative problem
an actual potential physiological complication that nurses monitor to detect the onset of changes in a client's status
North American Nursing Diagnosis Association (NANDA)
established to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
defining criteria
the clinical criteria or assessment findings that support an actual nursing diagnosis
clinical criteria
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
actual nursing diagnosis
describes human responses to health conditions or life processes that exist in an individual, family, or community--acute pain
risk diagnosis
describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community
health promotion nursing diagnosis
a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise
diagnostic label
the name of the nursing diagnosis as approved by NANDA International, it describes the essence of a client's response to health conditions in as few words as possible
related factors
a condition or etiology identified from the client's assessment data, associated with the client's actual or potential response to the health problem and can change by using nursing interventions
etiology
the cause of a disease, and is alway within the domain of nursing practice and a condition that responds to nursing interventions
planning
3rd step of nursing process; a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
priority setting
the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
goal
an aim, intent, or end; a broad statement that describes the desired change in a client's condition or behavior
expected outcomes
measurable criteria to evaluate goal achievement
client-centered goal
specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function
short-term goal
an objective behavior or response that you expect a client to achieve in a short time, usually less than a week
long-term goal
an objective behavior or response that you expect a client to achieve over a longer period; usually over several days, weeks, or months
guidelines for writing goals
client-centered
singular goal or outcome
observable
measurable
time-limited
mutual factors
realistic
types of interventions
independent nursing, dependent nursing, and collaborative interventions
independent nursing intervention
actions that a nurse initiates
dependent nursing intervention
physician initiated, actions that require an order from a physician or another health care professional
collaborative intervention
interdependent, therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
nursing care plan
enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care
scientific rationale
the reason that you chose a specific nursing action, based on supporting evidence
implementation
4th step of nursing process; formally begins after the nurse develops a plan of care
nursing intervention
any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
Implementation skill of nursing process
cognitive skills: application of critical thinking to nursing process
interpersonal skills: effective for nursing action-developing a relationship
psychomotor skills: integration of cognitive and interpersonal skills
evaluation
last step of nursing process; used to determine if after application of the nursing process, the client's condition or well-being improved (used to determine if you met expected outcomes, not if nursing interventions were completed)
standard of care
minimum level of care accepted to ensure high quality of care to clients; defines the types of therapies typically administered to clients with defined problems or needs
Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status?
Daily body weight
The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing?
Remove all four sides by moving to the center of the incision.
A male client ho is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." Which action should the PN implement first?
Assist the client to a supine position.
An older client who is unable to swallow is receiving continuous NGT feeding. Before administering medications through the NGT, what action should the practical nurse implement?
Flush the feeding tube with water.
Which action should the practical nurse implement to help a male client cope with his fear as he approaches death?
Hold the client's hand and tell him he is no alone.
The practical nurse is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement?
Obtain a soft-bristle brush for the client.
The practical nurse is caring for a client who is admitted with influenza and vomiting for 3 days. The clients skin turbot is poor and oral mucous membranes are dry. Which finding is most important for the PN to report to the charge nurse?
Hypotension and tachycardia
Which food should the practical nurse recommend for a client to increase the dietary intake of potassium?
Baked potatoes
When irrigating the external ear canals of an older adult client, which action should the PN use to soften dry cerumen for removal?
Instill mineral oil in the external auditory canal overnight before irrigation.
An older female state the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse take?
Check the written prescription to verify the medication
Which action should the PN implement when administering a subcutaneous injection to a client who weighs 325 pounds?
Select a needle with a longer shaft
Which intervention provides confirmation of NGT placement before NGT feedings are started?
X-ray of the abdomen
An older male client who is incontinent receives a prescription for a condom catheter. Which steps should the PN implement when applying the external catheter.
Wrap the adhesive strip in a spiral around the penis
Apply skin prep to the penile shaft and allow to dry
Leave 1-2 inches between the tip of the penis and condom catheter
Acetaminophen is prescribed for an unconscious client with a temp of 104' F. Which route should the PN plan to administer this medication?
Rectal
An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the PN that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first?
Digitally assess for impacted stool.
The PN is adding tap water to several medication for administration via feeding tube. Which preparation should the PN administer without delay?
Time release capsule
Which action should the PN follow when applying an elasticize bandage to a client's leg?
Overlap turns of the bandage equally
The PN obtains an elevated blood pressure reading for an older male client is is alert. When the PN offer the client his morning blood pressure medication, he refuses to take it. What action should the PN take?
Explain the importance of routine use of antihypertensives.
What position should the PN place client in who is receiving an enteral tube feeding?
Supine with the head of bed elevated to 30-45 degrees.
The PN is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site?
1 inch
An older male client tells the PN that his religion does not permit him to bathe daily. How should the PN respond?
Request that the client clarify his religious beliefs about bathing.
The PN identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN?
Bowel movements decreases to one every third day.
A client is prescribed a medication that is labeled as a sustained released (SR). What action should the PN implement when administering this drug form?
Do not crush or dissolve the table or capsule contents
The practical nurse is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. What nursing action should the PN take?
Mark the outlined area of drainage with date, time and initials
A client with gastroenteritis, nausea and vomiting is currently on NPO status. The healthcare provider prescribed oral intake to be advanced as towered. Which fluid should the PN offer first?
Water
Which time frame should the PN res position a client?
Every 2 hours
While taking an adult's vital signs, the PN notes an irregular radial pulse. What action should the PN implement to obtain the most accurate assessment?
Perform an apical-radial pulse assessment with another nurse
The practical nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase granulation tissue will develop within 2 weeks," which intervention should the PN implement.?
Irrigation of the wound with sterile normal saline
A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the PN implement to maximize the client's oxygenation?
Provide oxygen during rest periods between suctioning.
An older client who complains of dry mouth is having trouble swallowing pills. What action should the PN take when administering an enter-coated tablet?
Place the whole tablet in a spoonful of pudding.
The PN is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client?
Soybeans
The PN observes a client who begins to choke during a meal. After determining that the client cannot speak, what action should the PN implement?
Place a fist halfway between the xiphoid process and umbilicus.
The practical nurse is irrigation a clients indwelling catheter. After injecting sterile solution as prescribed what action should the PN implement?
Unclamped the tubing and lower the collection bag.
The PN hears breath sounds that are short, popping, and discontinuous on inspiration when auscultations a clients lungs. Which description should the PN document in the clients record?
Crackles auscultated
A male client is upset with the healthcare providers recommendation that he should consent to an above-knee amputation. He tells the PN, "If they want to cut off my left, they should just shoot me instead." How should the PN respond?
As the client how the surgery might effect his lifestyle
Which findings indicates to the PN that an older client who is receiving intravenous therapy is experiencing fluid overload?
Crackles in the lungs
Which action should the PN implement when supporting an older client who is afraid of dying?
Use open-ended questions to encourage the client to share feelings
A client is receiving a continuous tube feeding. While checking the gastric residual volume, the PN aspirated 150 mL of gastric contents. What action should the PN take?
Return all aspirated fluid to the stomach followed with water and consult agency policy.
The PN is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in the client?
The lips and mucous membranes of a client with dark skin are dusky in color
Which intervention should the PN implement to help a client cope effectively with chronic pain?
Encourage using relaxation techniques.
Which growth and developmental characteristics should the PN consider when discussing spiritually with an adolescent client?
Questions religious practices and values.
During the insertion of a NGT into the right nares, the client starts to cough. Which action should the PN implement?
Withdrawal the NGT to the oral pharynx, reposition the clients head and reinsert.
Which intervention should the PN use to prevent obstruction of a gastric feeding tube?
Obtain a prescription for a liquid drug form instead of crushing tablets.
A male Native American client with TB is visiting a health care clinic for a follow up treatment. During the interview, the PN notices that the client keeps his eyes on the flow and does make eye contact. How should the PN interprets this client's behavior?
His culture finds sustained eye contact rude or disrespectful
An 80 year old male client who has arthritis and who is having difficulty walking tells the PN, "It's awful to be old. It's seems as though everyday is a struggle. No one cares about an old person." What is the best response for the PN to provide?
It's sounds as though you are having a difficult time. Tell me about it.
An older female recently diagnosed with coronary artery diesel cooks at home using saturated fats. Which intervention should the PN implement to help the client reduce modifiable risk factors?
Encourage food preparation with various vegetable oils
What position should the PN place a client in who is receiving an enteral tube feeding?
Supine with the HOB elevated to 30-45 degrees.
The PN is applying a dry, sterile dressing to a clients abdominal wound. Which allergy should the PN verify with the client?
Tape
Which food should the PN recommend to a client as a source of complete protein?
Eggs
In planning care for an older client on bed rest, which intervention should the PN include in the prevention of pressure ulcers?
Elevate the HOB less than 30 degrees
Which action by the PN demonstrates the value of dignity in client care?
Closes the doors and covers the client during a bath.
The PN is obtaining information for a male clients psychosocial assessment. Which action should the PN implement first?
Establish a therapeutic relationship
What is the most important for the PN to include when performing pain assessment after giving an analgesic?
Use a pain scale to describe the intensity.
The PN is obtaining the vital signs for a client who has a urinary tract infection with MRSA. How should the PN proceed?
Don a gown and gloves before entering the room.
An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy to the PN to implement for the clients incontinence?
Establish a 2 hour voiding schedule
When irrigating the eyes of a client, which action should the PN implement?
Direct the irrigation flow from the inner canthus to the canthus of the affected eye.
A client whose diet is low in fiber is at risk for which condition?
Colon cancer
Which position is best for the PN to place the client in during administration of a rectal suppository for constipation?
Left sims position with upper leg flexed.
Which information should the PN provide a client who is selecting a site for self injection of insulin?
Rotate sites with the same location for a week before choosing a new location
The PN is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the clients comfort?
Perform oral hygiene frequently.
The PN is preparing to reconstitute a drug from powder form for IM administration. Which step should the PN implement first?
Verify the drug with MAR
Following a cholecystectomy, a client ask the PN about dietary restrictions that may need to be followed. Which diet should the PN recommend?
A well balanced diet with no other restrictions
A client is receiving a daily script for Lasik 40 mg PO but is unable to swallow. The PN should consult with the healthcare provider about which component of the prescription?
The route of adminstration
A family member of a dying client asks the PN if the client knows the family is at the bedside. The PN explains that which of the five senses persist the longest during the dying process?
Hearing
Which technique should the PN nurse use to give a Z-track IM injection?
Inject the med into the dorsal gluteal site
A client who has pressure relieving mattress overly is mobilized to a chair and imprints of the client buttocks, heels, and scapula are evident on the mattress overlay. What action should the PN implement?
Apply a different pressure relieving device and assess its effectiveness for this client
Which technique should the PN use to most accurately assess a clients baseline blood pressure during a routine health examination?
Measure the pressure in each arm while the clients sits with the arm supported at heart level.
What nutritional information should the PN provide a client with heart failure?
Restrict dietary sodium intake
Which interventions should the PN implement to reduce the incidence of UTI in a client with an indwelling catheter?
Cleanse the peri area with soap and water BID and PRN
The PN identifies a clients need for spiritual support. What is the first action the PN should take?
Determine the clients perceptions and belief systems.
A client is receiving a Mantoux test for TB screening. Which angle should the PN insert the needle for injection?
15 degrees
A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. The client expresses fear about becoming addicted to these drugs. What information should the PN provide?
Prescribe opiates for cancer pain relief improve qualify of life.
What action should the PN take when drawing meds from an ampule?
Aspirate with a filter needle and syringe.
The PN contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints?
To ensure the clients safety when the benefits outweighs the risks.
An older client is receiving NGT feedings for several days. Which finding should the PN report to the healthcare provider?
Abdominal distention and nausea
A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the PN priority intervention?
Obtain orthostatic blood pressures.
Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status?
Daily body weight
The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing?
Remove all four sides by moving to the center of the incision.
A male client ho is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." Which action should the PN implement first?
Assist the client to a supine position.
An older client who is unable to swallow is receiving continuous NGT feeding. Before administering medications through the NGT, what action should the practical nurse implement?
Flush the feeding tube with water.
Which action should the practical nurse implement to help a male client cope with his fear as he approaches death?
Hold the client's hand and tell him he is no alone.
The practical nurse is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement?
Obtain a soft-bristle brush for the client.
The practical nurse is caring for a client who is admitted with influenza and vomiting for 3 days. The clients skin turbot is poor and oral mucous membranes are dry. Which finding is most important for the PN to report to the charge nurse?
Hypotension and tachycardia
Which food should the practical nurse recommend for a client to increase the dietary intake of potassium?
Baked potatoes
When irrigating the external ear canals of an older adult client, which action should the PN use to soften dry cerumen for removal?
Instill mineral oil in the external auditory canal overnight before irrigation.
An older female state the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse take?
Check the written prescription to verify the medication
Which action should the PN implement when administering a subcutaneous injection to a client who weighs 325 pounds?
Select a needle with a longer shaft
Which intervention provides confirmation of NGT placement before NGT feedings are started?
X-ray of the abdomen
An older male client who is incontinent receives a prescription for a condom catheter. Which steps should the PN implement when applying the external catheter.
Wrap the adhesive strip in a spiral around the penis
Apply skin prep to the penile shaft and allow to dry
Leave 1-2 inches between the tip of the penis and condom catheter
Acetaminophen is prescribed for an unconscious client with a temp of 104' F. Which route should the PN plan to administer this medication?
Rectal
An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the PN that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first?
Digitally assess for impacted stool.
The PN is adding tap water to several medication for administration via feeding tube. Which preparation should the PN administer without delay?
Time release capsule
Which action should the PN follow when applying an elasticize bandage to a client's leg?
Overlap turns of the bandage equally
The PN obtains an elevated blood pressure reading for an older male client is is alert. When the PN offer the client his morning blood pressure medication, he refuses to take it. What action should the PN take?
Explain the importance of routine use of antihypertensives.
What position should the PN place client in who is receiving an enteral tube feeding?
Supine with the head of bed elevated to 30-45 degrees.
The PN is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site?
1 inch
An older male client tells the PN that his religion does not permit him to bathe daily. How should the PN respond?
Request that the client clarify his religious beliefs about bathing.
The PN identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN?
Bowel movements decreases to one every third day.
A client is prescribed a medication that is labeled as a sustained released (SR). What action should the PN implement when administering this drug form?
Do not crush or dissolve the table or capsule contents
The practical nurse is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. What nursing action should the PN take?
Mark the outlined area of drainage with date, time and initials
A client with gastroenteritis, nausea and vomiting is currently on NPO status. The healthcare provider prescribed oral intake to be advanced as towered. Which fluid should the PN offer first?
Water
Which time frame should the PN res position a client?
Every 2 hours
While taking an adult's vital signs, the PN notes an irregular radial pulse. What action should the PN implement to obtain the most accurate assessment?
Perform an apical-radial pulse assessment with another nurse
The practical nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase granulation tissue will develop within 2 weeks," which intervention should the PN implement.?
Irrigation of the wound with sterile normal saline
A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the PN implement to maximize the client's oxygenation?
Provide oxygen during rest periods between suctioning.
An older client who complains of dry mouth is having trouble swallowing pills. What action should the PN take when administering an enter-coated tablet?
Place the whole tablet in a spoonful of pudding.
The PN is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client?
Soybeans
The PN observes a client who begins to choke during a meal. After determining that the client cannot speak, what action should the PN implement?
Place a fist halfway between the xiphoid process and umbilicus.
The practical nurse is irrigation a clients indwelling catheter. After injecting sterile solution as prescribed what action should the PN implement?
Unclamped the tubing and lower the collection bag.
The PN hears breath sounds that are short, popping, and discontinuous on inspiration when auscultations a clients lungs. Which description should the PN document in the clients record?
Crackles auscultated
A male client is upset with the healthcare providers recommendation that he should consent to an above-knee amputation. He tells the PN, "If they want to cut off my left, they should just shoot me instead." How should the PN respond?
As the client how the surgery might effect his lifestyle
Which findings indicates to the PN that an older client who is receiving intravenous therapy is experiencing fluid overload?
Crackles in the lungs
Which action should the PN implement when supporting an older client who is afraid of dying?
Use open-ended questions to encourage the client to share feelings
A client is receiving a continuous tube feeding. While checking the gastric residual volume, the PN aspirated 150 mL of gastric contents. What action should the PN take?
Return all aspirated fluid to the stomach followed with water and consult agency policy.
The PN is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in the client?
The lips and mucous membranes of a client with dark skin are dusky in color
Which intervention should the PN implement to help a client cope effectively with chronic pain?
Encourage using relaxation techniques.
Which growth and developmental characteristics should the PN consider when discussing spiritually with an adolescent client?
Questions religious practices and values.
During the insertion of a NGT into the right nares, the client starts to cough. Which action should the PN implement?
Withdrawal the NGT to the oral pharynx, reposition the clients head and reinsert.
Which intervention should the PN use to prevent obstruction of a gastric feeding tube?
Obtain a prescription for a liquid drug form instead of crushing tablets.
A male Native American client with TB is visiting a health care clinic for a follow up treatment. During the interview, the PN notices that the client keeps his eyes on the flow and does make eye contact. How should the PN interprets this client's behavior?
His culture finds sustained eye contact rude or disrespectful
An 80 year old male client who has arthritis and who is having difficulty walking tells the PN, "It's awful to be old. It's seems as though everyday is a struggle. No one cares about an old person." What is the best response for the PN to provide?
It's sounds as though you are having a difficult time. Tell me about it.
An older female recently diagnosed with coronary artery diesel cooks at home using saturated fats. Which intervention should the PN implement to help the client reduce modifiable risk factors?
Encourage food preparation with various vegetable oils
What position should the PN place a client in who is receiving an enteral tube feeding?
Supine with the HOB elevated to 30-45 degrees.
The PN is applying a dry, sterile dressing to a clients abdominal wound. Which allergy should the PN verify with the client?
Tape
Which food should the PN recommend to a client as a source of complete protein?
Eggs
In planning care for an older client on bed rest, which intervention should the PN include in the prevention of pressure ulcers?
Elevate the HOB less than 30 degrees
Which action by the PN demonstrates the value of dignity in client care?
Closes the doors and covers the client during a bath.
The PN is obtaining information for a male clients psychosocial assessment. Which action should the PN implement first?
Establish a therapeutic relationship
What is the most important for the PN to include when performing pain assessment after giving an analgesic?
Use a pain scale to describe the intensity.
The PN is obtaining the vital signs for a client who has a urinary tract infection with MRSA. How should the PN proceed?
Don a gown and gloves before entering the room.
An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy to the PN to implement for the clients incontinence?
Establish a 2 hour voiding schedule
When irrigating the eyes of a client, which action should the PN implement?
Direct the irrigation flow from the inner canthus to the canthus of the affected eye.
A client whose diet is low in fiber is at risk for which condition?
Colon cancer
Which position is best for the PN to place the client in during administration of a rectal suppository for constipation?
Left sims position with upper leg flexed.
Which information should the PN provide a client who is selecting a site for self injection of insulin?
Rotate sites with the same location for a week before choosing a new location
The PN is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the clients comfort?
Perform oral hygiene frequently.
The PN is preparing to reconstitute a drug from powder form for IM administration. Which step should the PN implement first?
Verify the drug with MAR
Following a cholecystectomy, a client ask the PN about dietary restrictions that may need to be followed. Which diet should the PN recommend?
A well balanced diet with no other restrictions
A client is receiving a daily script for Lasik 40 mg PO but is unable to swallow. The PN should consult with the healthcare provider about which component of the prescription?
The route of adminstration
A family member of a dying client asks the PN if the client knows the family is at the bedside. The PN explains that which of the five senses persist the longest during the dying process?
Hearing
Which technique should the PN nurse use to give a Z-track IM injection?
Inject the med into the dorsal gluteal site
A client who has pressure relieving mattress overly is mobilized to a chair and imprints of the client buttocks, heels, and scapula are evident on the mattress overlay. What action should the PN implement?
Apply a different pressure relieving device and assess its effectiveness for this client
Which technique should the PN use to most accurately assess a clients baseline blood pressure during a routine health examination?
Measure the pressure in each arm while the clients sits with the arm supported at heart level.
What nutritional information should the PN provide a client with heart failure?
Restrict dietary sodium intake
Which interventions should the PN implement to reduce the incidence of UTI in a client with an indwelling catheter?
Cleanse the peri area with soap and water BID and PRN
The PN identifies a clients need for spiritual support. What is the first action the PN should take?
Determine the clients perceptions and belief systems.
A client is receiving a Mantoux test for TB screening. Which angle should the PN insert the needle for injection?
15 degrees
A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. The client expresses fear about becoming addicted to these drugs. What information should the PN provide?
Prescribe opiates for cancer pain relief improve qualify of life.
What action should the PN take when drawing meds from an ampule?
Aspirate with a filter needle and syringe.
The PN contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints?
To ensure the clients safety when the benefits outweighs the risks.
An older client is receiving NGT feedings for several days. Which finding should the PN report to the healthcare provider?
Abdominal distention and nausea
A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the PN priority intervention?
Obtain orthostatic blood pressures.
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?

A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C) Examining a chest x-ray obtained after the tubing was inserted

Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the

A) Arms.
B) Upper torso.
C) Head.
D) Feet
B) Upper torso

The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer.
Which action is most important for the nurse to implement when donning sterile gloves?

A) Maintain thumb at a ninety degree angle.
B) Hold hands with fingers down while gloving.
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first.
C) Keep gloved hands above the elbows

Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?

A) It is important that you continue your medication while learning to meditate.
B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C) Obtain your healthcare provider's permission before starting meditation.
D) Complementary therapy and western medicine can be effective for you.
A) It is important that you continue your medication while learning to meditate

The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment?

A) Client.
B) Healthcare provider.
C) A family member.
D) Previous medical records
A) Client

A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

A) If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B) I need to avoid eating proteins, including red meat.
C) I will limit my intake of beef to 4 ounces per week.
D) My blood level of low density lipoproteins needs to increase.
C) I will limit my intake of beef to 4 ounces per week

Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?

A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter

Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?

A) What is your daily calorie consumption?
B) What vitamin and mineral supplements do you take?
C) Do you feel that you are overweight?
D) Will a clear liquid diet be okay after surgery?
A) What is your daily calorie consumption?

Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?

A) Encourage the client to cough to help loosen secretions.
B) Advise the client to increase the intake of oral fluids.
C) Rotate the suction catheter to obtain any remaining secretions.
D) Re-oxygenate the client before attempting to suction again.
D) Re-oxygenate the client before attempting to suction again

Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?

A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube

Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?

A) Irrigate the nasogastric tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the nasogastric tube an additional five centimeters.
D) Administer an intravenous antiemetic prescribed for PRN use.
B) Reposition the client on her side

The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

A) Place the chair at a right angle to the bed on the client's left side before moving.
B) Assist the client to a standing position, then place the right hand on the armrest.
C) Have the client place the left foot next to the chair and pivot to the left before sitting.
D) Move the chair parallel to the right side of the bed, and stand the client on the right foot
D) Move the chair parallel to the right side of the bed, and stand the client on the right foot

(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?

A) Complimentary healing practices interfere with the efficacy of the medical model of treatment.
B) Conventional medications are likely to interact with folk remedies and cause adverse effects.
C) Many complimentary healing practices can be used in conjunction with conventional practices.
D) Conventional medical practices will ultimately replace the use of complimentary healing practices.
C) Many complimentary healing practices can be used in conjunction with conventional practices

Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).
After completing an assessment and determining that a client has a problem, which action should the nurse perform next?

A) Determine the etiology of the problem.
B) Prioritize nursing care interventions.
C) Plan appropriate interventions.
D) Collaborate with the client to set goals.
A) Determine the etiology of the problem

Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?

A) The belief is held that the "evil eye" enters the child if anything cold is ingested.
B) After surgery the child probably has refused all foods except broth.
C) Eating broth strengthens the child's innate energy called "chi."
D) Hot remedies restore balance after surgery, which is considered a "cold" condition.
D) Hot remedies restore balance after surgery, which is considered a "cold" condition

Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?

A) Reassure the client that he will become accustomed to the stoma appearance in time.
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes.
C) Offer to contact a member of the local ostomy support group to help him with his concerns.
D) Encourage the client to handle the stoma equipment to gain confidence with the procedure
B) Instruct the client that the stoma will beco