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Questions and Answers
Which of the following indications might suggest malnutrition? (Select all that apply)
Which of the following indications might suggest malnutrition? (Select all that apply)
An elevated temperature can indicate malnutrition.
An elevated temperature can indicate malnutrition.
False
A nurse should first _____ followed by _____.
A nurse should first _____ followed by _____.
review medications that might be causing confusion, using other methods to keep the client safe
Which actions should the nurse plan to take for the client? (Select the 3 actions)
Which actions should the nurse plan to take for the client? (Select the 3 actions)
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Which statements indicate understanding of teaching for a client with heart failure? (Select the 3 statements)
Which statements indicate understanding of teaching for a client with heart failure? (Select the 3 statements)
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Which instructions should the nurse include for a client with diarrhea? (Select the 4 instructions)
Which instructions should the nurse include for a client with diarrhea? (Select the 4 instructions)
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What indicates a client's readiness to learn?
What indicates a client's readiness to learn?
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Which statement indicates a client is not ready to learn?
Which statement indicates a client is not ready to learn?
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What should a nurse instruct family members of a client with Clostridium difficile infection?
What should a nurse instruct family members of a client with Clostridium difficile infection?
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What is the correct statement regarding a 24-hr urine collection?
What is the correct statement regarding a 24-hr urine collection?
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Which response should a nurse give to a middle adult feeling useless due to independence of children?
Which response should a nurse give to a middle adult feeling useless due to independence of children?
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What type of precautions should be taken for a client with rubella?
What type of precautions should be taken for a client with rubella?
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What is the correct age for receiving a pneumococcal vaccine?
What is the correct age for receiving a pneumococcal vaccine?
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Which tasks can an assistive personal (AP) perform for a client who has had a stroke?
Which tasks can an assistive personal (AP) perform for a client who has had a stroke?
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What is the first step after a client dies during a nurse's shift?
What is the first step after a client dies during a nurse's shift?
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What should the nurse do when caring for a client with shigella?
What should the nurse do when caring for a client with shigella?
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Indicate a statement that shows a client is ready for palliative care information.
Indicate a statement that shows a client is ready for palliative care information.
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What is the priority action during a dressing change for a postoperative client?
What is the priority action during a dressing change for a postoperative client?
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What objective statement should be documented after a client falls?
What objective statement should be documented after a client falls?
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What action should a nurse take to prevent self-injury when lifting a bedside cabinet?
What action should a nurse take to prevent self-injury when lifting a bedside cabinet?
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Which action is appropriate for a nurse caring for a client with frequent tonic-clonic seizures?
Which action is appropriate for a nurse caring for a client with frequent tonic-clonic seizures?
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Restraining a client who is having a seizure increases their risk for injury.
Restraining a client who is having a seizure increases their risk for injury.
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During seizure activity, the nurse should turn the client to the side so that the tongue does not occlude the ________.
During seizure activity, the nurse should turn the client to the side so that the tongue does not occlude the ________.
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Which task can the nurse safely delegate to an assistive personnel (AP)?
Which task can the nurse safely delegate to an assistive personnel (AP)?
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Which finding indicates fluid volume excess?
Which finding indicates fluid volume excess?
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Which documentation practice should be taught regarding magnesium sulfate?
Which documentation practice should be taught regarding magnesium sulfate?
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What indicates correct placement of a nasogastric tube?
What indicates correct placement of a nasogastric tube?
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Which question should the nurse ask to assess the quality of a client's pain?
Which question should the nurse ask to assess the quality of a client's pain?
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What should a nurse do during medication reconciliation?
What should a nurse do during medication reconciliation?
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What precaution should a nurse plan for a client who has had an allogeneic stem cell transplant?
What precaution should a nurse plan for a client who has had an allogeneic stem cell transplant?
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Which transmission precautions should a nurse initiate for a client with an abdominal wound?
Which transmission precautions should a nurse initiate for a client with an abdominal wound?
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The nurse should first address the client's ________ followed by the client's ________.
The nurse should first address the client's ________ followed by the client's ________.
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Which findings should the nurse report for a client with a pressure injury?
Which findings should the nurse report for a client with a pressure injury?
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Which assessment finding should a nurse report for a postoperative client?
Which assessment finding should a nurse report for a postoperative client?
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Which actions should the nurse take upon admitting a client with pneumonia?
Which actions should the nurse take upon admitting a client with pneumonia?
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Which findings indicate that a client is malnourished?
Which findings indicate that a client is malnourished?
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Which of the following findings should the nurse expect for a client with a sodium level of 125 mEq/L?
Which of the following findings should the nurse expect for a client with a sodium level of 125 mEq/L?
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Which client statement indicates an understanding of herbal supplement use?
Which client statement indicates an understanding of herbal supplement use?
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What action should the nurse take while irrigating a client's urinary catheter?
What action should the nurse take while irrigating a client's urinary catheter?
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Which of the following changes should the nurse identify as an indication that the treatment was successful for a postoperative client with fluid volume deficit?
Which of the following changes should the nurse identify as an indication that the treatment was successful for a postoperative client with fluid volume deficit?
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What type of role-performance stress is the partner of a dementia patient experiencing?
What type of role-performance stress is the partner of a dementia patient experiencing?
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What intervention should the nurse include in the care plan for a client with vision loss?
What intervention should the nurse include in the care plan for a client with vision loss?
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Which of the following responses made by the nurse is appropriate when a client's family questions about the transfer to a long-term care facility?
Which of the following responses made by the nurse is appropriate when a client's family questions about the transfer to a long-term care facility?
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What should the nurse instruct while caring for a client using a PCA pump?
What should the nurse instruct while caring for a client using a PCA pump?
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Which laboratory result would be a priority for the nurse to report to the provider for a female client who has hypovolemia?
Which laboratory result would be a priority for the nurse to report to the provider for a female client who has hypovolemia?
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Which recommendation should the nurse make to a client who reports difficulty falling asleep?
Which recommendation should the nurse make to a client who reports difficulty falling asleep?
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What precaution should the nurse take for a client with a latex allergy?
What precaution should the nurse take for a client with a latex allergy?
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What action should the nurse take for a client refusing a blood transfusion for religious reasons?
What action should the nurse take for a client refusing a blood transfusion for religious reasons?
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What action should the nurse take regarding a client who has a new prescription for wrist restraints?
What action should the nurse take regarding a client who has a new prescription for wrist restraints?
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After confirming the presence of a fire reported by a nonambulatory client, which action should the nurse take next?
After confirming the presence of a fire reported by a nonambulatory client, which action should the nurse take next?
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What type of dressing should the nurse use for a stage 2 pressure injury?
What type of dressing should the nurse use for a stage 2 pressure injury?
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How many mL/hr should the nurse set the infusion pump to deliver when administering 0.9% sodium chloride 750 mL IV over 7 hr?
How many mL/hr should the nurse set the infusion pump to deliver when administering 0.9% sodium chloride 750 mL IV over 7 hr?
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What actions should the nurse take for a client with tuberculosis? (Select all that apply)
What actions should the nurse take for a client with tuberculosis? (Select all that apply)
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Which physical assessment technique should the nurse use when assessing adult clients?
Which physical assessment technique should the nurse use when assessing adult clients?
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What should the nurse do for a client showing signs of hemorrhagic shock?
What should the nurse do for a client showing signs of hemorrhagic shock?
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What should the nurse say when caring for a client with a terminal diagnosis who requests information about advance directives?
What should the nurse say when caring for a client with a terminal diagnosis who requests information about advance directives?
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What intervention should the nurse take first for a client with difficulty breathing?
What intervention should the nurse take first for a client with difficulty breathing?
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Which observation indicates proper safety protocols for a client receiving supplemental oxygen?
Which observation indicates proper safety protocols for a client receiving supplemental oxygen?
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When should the nurse initiate discharge planning for a client with an exacerbation of heart failure?
When should the nurse initiate discharge planning for a client with an exacerbation of heart failure?
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Which statement should the nurse identify as indicating that the client understands the preoperative teaching they received about pain management?
Which statement should the nurse identify as indicating that the client understands the preoperative teaching they received about pain management?
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What action should the nurse take to prevent skin breakdown in a client with limited mobility?
What action should the nurse take to prevent skin breakdown in a client with limited mobility?
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Which statement indicates a client's readiness to learn about insulin self-administration?
Which statement indicates a client's readiness to learn about insulin self-administration?
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Which of the following findings should the nurse expect when completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days?
Which of the following findings should the nurse expect when completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days?
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Which action should the nurse take first when caring for a client with a nasogastric (NG) tube receiving intermittent feedings?
Which action should the nurse take first when caring for a client with a nasogastric (NG) tube receiving intermittent feedings?
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Which intervention should the nurse include in the plan of care for an adolescent who is postoperative following a lumbar laminectomy?
Which intervention should the nurse include in the plan of care for an adolescent who is postoperative following a lumbar laminectomy?
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Which finding indicates that a client with an indwelling urinary catheter requires irrigation?
Which finding indicates that a client with an indwelling urinary catheter requires irrigation?
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Study Notes
Fluid Volume Deficit Management
- Successful treatment of fluid volume deficit is indicated by a decrease in heart rate, as tachycardia is a symptom of this condition.
- Hematocrit levels may initially rise due to fluid loss but should decrease with treatment, contrary to heart rate improvement.
- Respiratory rate and capillary refill time should normalize with effective treatment.
Communication with Families
- Therapeutic communication is facilitated by engaging family members in discussions about client care, rather than dismissing or defending against their concerns.
Laboratory Value Prioritization
- A potassium level of 5.8 mEq/L requires urgent attention as it poses a risk for dysrhythmias, while other values like BUN and creatinine, although abnormal, are non-urgent.
Sleep Improvement Techniques
- Maintaining a consistent wake-up time each day promotes better sleep patterns, while caffeine consumption and late exercise can disrupt sleep quality.
Restraint Protocols
- Proper care for clients with wrist restraints includes padding to prevent injury, evaluating circulation every 15 minutes, and ensuring restraints are easily removable for repositioning and hygiene.
Fire Safety Response
- The RACE mnemonic outlines priority actions during a fire: Rescue clients first (evacuate), then Alarm (activate the fire alarm), Contain (close doors/windows), and Extinguish the fire if safe.
IV Infusion Calculation
- To infuse 750 mL of 0.9% sodium chloride over 7 hours, set the infusion pump to deliver 107 mL/hr.
Adult Client Assessment Techniques
- Proper blood pressure cuff use requires the bladder to encircle 80% of the arm for accurate readings; age-appropriate pain scales and the correct location for auscultation are crucial for accurate assessments.
Advance Directives Discussion
- When discussing advance directives, offering resources while directly addressing the client's needs fosters trust and connection, as opposed to postponing the conversation or shifting the responsibility.
Discharge Planning
- Initiate discharge planning during the admission process to ensure comprehensive care and meet client needs throughout their hospital stay.
Postoperative Pain Management
- Understanding that mild pain (2 on a scale of 0-10) can be effectively managed through non-pharmacological methods demonstrates patient knowledge of pain management techniques.
Expected Findings with Fluid Loss
- Rapid heart rate is a common indicator of fluid volume deficit, while findings like neck vein distention are associated with fluid excess.
NG Tube Care Priorities
- Keeping the head of the bed elevated at least 30 degrees is critical to prevent aspiration during enteral feeding.
Adolescent Independence in Care
- Allowing adolescents to make decisions regarding their care promotes independence, which is essential during recovery from surgery.
Indications for Urinary Catheter Irrigation
- A bladder scan revealing 525 mL of urine necessitates irrigation to prevent blockage and ensure proper urine flow.
Symptoms of Hyponatremia
- Abdominal cramping is a common manifestation of low sodium levels, while symptoms like bradycardia and numbness are indicative of different electrolyte imbalances.
Understanding Herbal Supplements
- Echinacea is recognized for its immune-boosting properties; other herbs serve different purposes but misconceptions about their effects should be clarified to ensure proper use.### Catheter Irrigation
- For catheter irrigation, subtract the amount of irrigant used from the client's total urinary output to maintain accurate fluid balance.
- Position the client in a supine or dorsal recumbent position for optimal access during irrigation procedures.
Role-Performance Stress in Caregivers
- Role overload occurs when a caregiver has more responsibilities than they can manage, often leading to frustration.
- Role ambiguity involves unclear expectations, while the sick role pertains to those with health alterations, and role conflict surfaces when multiple roles have opposing expectations.
Caring for Clients with Vision Loss
- Arrange food in a consistent pattern on the plate to facilitate self-feeding for clients with vision loss.
- Use large-handled, adaptive utensils rather than small ones to improve grip and independence.
PCA Pump Management
- Educate family to avoid pushing the PCA button for a sleeping client, minimizing overdose risks.
- Regular vital sign monitoring is essential within 1 to 2 hours, rather than every 8 hours.
Latex Allergy Precautions
- Cover monitoring cords with stockinette to prevent contact with latex, essential for clients with latex allergies.
- Avoid using latex gloves, even if hypoallergenic, due to potential allergic reactions.
Autonomy in Medical Treatment
- Respect a client’s autonomy by withholding treatment they refuse, even if family members disagree.
- No need to involve the ethics committee as a competent client has the right to refuse treatment.
Dressing for Pressure Injuries
- Hydrocolloid dressings are most suitable for healing stage 2 pressure injuries by maintaining a moist environment.
- Alginate dressings are intended for more severe injuries due to their drainage absorption capabilities.
Tuberculosis Precautions
- Utilize negative-pressure rooms and ensure proper hand hygiene with antimicrobial sanitizers when caring for clients with tuberculosis.
- N95 respirators are necessary for nurses, while gloves are required for personal care.
Hemorrhagic Shock Nursing Actions
- Notify the nursing manager to ensure immediate action for a client in hemorrhagic shock before documenting or filling incident reports.
Client Positioning for Breathing Difficulties
- Sit clients upright to maximize oxygen delivery and facilitate breathing effectiveness.
Home Safety for Oxygen Use
- Clients should identify fire extinguisher locations; however, do not use wool blankets due to static electricity risks.
- Store extra oxygen tanks upright to prevent hazards.
Skin Breakdown Prevention
- Encourage using a trapeze bar to minimize friction during repositioning to reduce skin breakdown risks.
- Maintain balanced nutrition, focusing on protein intake to support tissue repair.
Client Readiness to Learn
- Indicate willingness to learn by expressing optimal learning times; the client’s discomfort with inadequate tools or reluctance suggests unpreparedness.
Clostridium Difficile Infection Protocol
- Ensure that family members wear protective gowns and gloves to prevent the transmission of spores; thorough hand hygiene with soap and water is essential.
24-Hour Urine Collection Instructions
- Correct procedure involves discarding the first void and retaining all urine thereafter; immediate collection ensures accuracy in the 24-hour test.
Middle Adult Client's Emotional State
- Address feelings of uselessness following children's independence with supportive, empathetic communication to validate their emotions.### Developmental Stages and Client Care
- Middle adulthood is characterized by the psychosocial task of generativity versus self-absorption, as described by Erik Erikson.
- Generativity includes nurturing others, particularly through mentoring and voluntary support.
- Common misconceptions include the belief that parents should automatically be happy when children leave home, while feelings of being unneeded may arise need exploring.
Infection Control Precautions
- Clients with rubella require droplet precautions due to transmission via larger droplet nuclei.
- Airborne infections (like tuberculosis) and contact infections (like MRSA) require different precautions.
- Protective environments are necessary for immunocompromised patients, not those with droplet-transmissible infections.
Health Recommendations for Older Adults
- Older adults should receive the pneumococcal vaccine at age 65.
- Routine eye examinations should occur annually, not every two years.
- Tetanus boosters should be given every 10 years, and shingles vaccines at 60 years, not 70.
Client Care and Delegation
- Assistive personnel (AP) can be delegated lower-risk activities like partial bed baths and vital signs measurement.
- Tasks like evaluating swallowing or irrigating indwelling catheters are outside the AP's scope due to the need for clinical assessment.
Post-Mortem Care
- Upon a client’s death, the first steps are to obtain the pronouncement of death and remove tubes and lines.
- After cleansing the body, the family can be offered a chance to view the remains, followed by placing a name tag on the body.
Seizure Management
- Blanket wrapping around the bed can help protect clients from injury during tonic-clonic seizures.
- Restraints are contraindicated as they can increase the risk of injury, and inserting objects in the mouth is unsafe.
Documentation Best Practices
- Accurate documentation should focus on objective observations, such as "Client found lying on the floor," avoiding subjective interpretations.
- Proper abbreviations and complete names of medications are critical to avoid misinterpretation and medication errors.
Identifying Fluid Volume Status
- Distended neck veins indicate fluid volume excess, while a weak pulse and hypotension suggest volume deficit.
- Common indicators of excess include crackles in lungs and edema.
NG Tube Placement Confirmation
- Correct placement of an NG tube is confirmed by an x-ray showing the tube positioned above the pylorus.
- Gastric aspirate pH should be 5 or less; a pH of 7 suggests inappropriate placement.
Assessing Pain Quality
- When assessing pain, open-ended questions should encourage clients to describe their pain quality, providing insight for tailored intervention.
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Test your knowledge on fluid volume deficit and postoperative care with these ATI RN fundamentals flashcards. This quiz provides crucial insights related to patient care, vital signs, and nursing interventions. It's essential for nursing students preparing for the RN exam.
