HESI EXAM 1 Study Guide
194 Questions
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HESI EXAM 1 Study Guide

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Questions and Answers

What is the maximum wear time for a hydro colloid dressing?

  • 10 days
  • 3 days
  • 5 days
  • 7 days (correct)

    • Under which condition should a calcium alginate dressing be used?

  • For minor cuts
  • In infected wounds
  • For dry wounds
  • When there is significant exudate (correct)

    • What should be done if a hydrogel dressing becomes compromised?

  • Leave it on for longer
  • Change it immediately (correct)
  • Evaluate effectiveness after 14 days
  • Apply another dressing on top

    • Which type of dressing is used to protect a wound from environmental damage?

    <p>Foam dressing</p> Signup and view all the answers

    What is the primary function of gauze dressings?

    <p>Absorb moisture</p> Signup and view all the answers

    What is the most appropriate action for the nurse regarding the feeding rate?

    <p>Increase the rate of the formula to 40 mL/hour.</p> Signup and view all the answers

    Which crucial information should the nurse collect before discharge instructions?

    <p>Determine if they feel ready to learn the skill.</p> Signup and view all the answers

    How should the nurse proceed when the spouse is emotional during equipment demonstration?

    <p>Acknowledge the stress and check if he wants to continue.</p> Signup and view all the answers

    When observing the spouse administering a bolus feeding, what should the nurse do?

    <p>Ensure he flushes the tubing with water afterward.</p> Signup and view all the answers

    What should be the initial nursing action when administering bolus feeding?

    <p>Tell the spouse to hold the remaining feeding.</p> Signup and view all the answers

    What is a priority when the spouse demonstrates administering feeding?

    <p>Assess if the spouse is comfortable with the equipment.</p> Signup and view all the answers

    What strategy is essential before transitioning to bolus feedings?

    <p>Determine their knowledge of signs of complications.</p> Signup and view all the answers

    In the context of nutrition education, what should the nurse emphasize most?

    <p>Methods for managing any potential feeding intolerance.</p> Signup and view all the answers

    What is the most appropriate action for the nurse to take for the client's inflamed areas?

    <p>Identify the areas as sites of pressure damage</p> Signup and view all the answers

    Which factor is the most accurate etiology for the client's condition?

    <p>Limited physical mobility</p> Signup and view all the answers

    In the care plan for the client, which goal should the nurse prioritize?

    <p>Skin integrity will not deteriorate</p> Signup and view all the answers

    To provide effective pressure relief at night, which position should the nurse advise the client to adopt?

    <p>Thirty-degree lateral inclined position</p> Signup and view all the answers

    What should the nurse reinforce regarding the use of a pressure-reducing gel cushion?

    <p>Encourage continuous use for effective pressure relief</p> Signup and view all the answers

    For a stage 1 pressure injury (PI), which dressing is most appropriate?

    <p>Transparent film dressing</p> Signup and view all the answers

    In documenting wound drainage, which term should the nurse use for clear fluid?

    <p>Serous</p> Signup and view all the answers

    What is the best intervention for reducing moisture's impact on the client’s skin?

    <p>Implement a moisture-repellent ointment</p> Signup and view all the answers

    What characteristic of urine suggests a fluid volume deficit in a patient?

    <p>Dark amber urine</p> Signup and view all the answers

    Which liquid is most beneficial for a patient with fluid volume deficit?

    <p>Orange juice</p> Signup and view all the answers

    When assessing for orthostatic vital sign changes, what is the nurse's first action?

    <p>Position Donna in a supine position</p> Signup and view all the answers

    What is a critical indicator of fluid volume status in this patient?

    <p>Body weight</p> Signup and view all the answers

    What should the nurse do after recording the initial blood pressure measurement?

    <p>Assess for an auscultatory gap</p> Signup and view all the answers

    Which finding would suggest worsening fluid volume deficit in the patient?

    <p>Inelastic skin turgor</p> Signup and view all the answers

    Donna is prescribed hydrochlorothiazide. What is the primary concern related to this medication?

    <p>It acts as a diuretic and may worsen fluid volume deficit</p> Signup and view all the answers

    Which symptom is least likely associated with fluid volume deficit?

    <p>Accumulation of fluid in tissues</p> Signup and view all the answers

    Which member of the interprofessional team should the nurse obtain an order from to address the client's nutritional challenges?

    <p>Registered dietician</p> Signup and view all the answers

    When seeking consultation for dysphagia issues, which interprofessional team member should the nurse approach?

    <p>Clinical nutritionist</p> Signup and view all the answers

    What is the most appropriate instruction for the nurse to give the UAP before assisting the client with meals?

    <p>Help feed the client first and allow rest with the head lowered.</p> Signup and view all the answers

    In managing dysphagia precautions, which action should the nurse prioritize?

    <p>Instruct the UAP to add a thickening agent to all liquids.</p> Signup and view all the answers

    Which symptom could indicate that the nurse needs to further evaluate the client's nutrition?

    <p>Rough, dry, scaly, and pale skin</p> Signup and view all the answers

    Which clinical sign reflects potential nutritional deficiencies in the client?

    <p>The lips are dry and cracked</p> Signup and view all the answers

    What could be a critical hydration recommendation for a client with dysphagia?

    <p>Room temperature fluids are the best option for safety.</p> Signup and view all the answers

    What common misconception might lead to unsafe feeding practices for a client with dysphagia?

    <p>That all foods can be administered in any form.</p> Signup and view all the answers

    What is the primary purpose of using hydrogel dressings on wounds?

    <p>To provide a moist healing environment</p> Signup and view all the answers

    In which situation is calcium alginate dressing most appropriately applied?

    <p>When there is significant exudate from the wound</p> Signup and view all the answers

    What is a key characteristic of foam dressings regarding their usage?

    <p>Used to cover and protect wounds while absorbing excess exudate</p> Signup and view all the answers

    What should be evaluated before changing a hydrocolloid dressing?

    <p>The duration the dressing has been in place</p> Signup and view all the answers

    What is a main advantage of using gauze dressings?

    <p>They promote debridement through absorption</p> Signup and view all the answers

    What is the primary goal of hospice care for patients and families?

    <p>To ensure care continues without interruption during setting changes.</p> Signup and view all the answers

    Which description best characterizes the support provided by hospice team members?

    <p>They provide 24/7 support and are available for urgent needs.</p> Signup and view all the answers

    What immediate action should a nurse take when a client with pneumonia shows a decrease in oxygen saturation?

    <p>Assist the client back to bed to minimize oxygen demand.</p> Signup and view all the answers

    In the nursing assessment process, after identifying a problem, what should the nurse do next?

    <p>Determine the underlying cause of the problem.</p> Signup and view all the answers

    How many azithromycin tablets should a nurse administer per dose if prescribed 500 mg and it's available as 250 mg tablets?

    <p>2 tablets</p> Signup and view all the answers

    When a client becomes upset after observing their colostomy for the first time, what is the most supportive response from the nurse?

    <p>Acknowledge the client's feelings and offer reassurance.</p> Signup and view all the answers

    What aspect of hospice care ensures that patients can maintain dignity until death?

    <p>Collaboration among a team of healthcare professionals.</p> Signup and view all the answers

    What critical situation arises when a client experiences oxygen saturation below 90%?

    <p>It indicates the need for immediate emergency intervention.</p> Signup and view all the answers

    What condition might the nurse suspect if a patient exhibits rebound tenderness and involuntary rigidity of the abdomen?

    <p>Appendicitis</p> Signup and view all the answers

    Which assessment technique is most appropriate to confirm a problem specifically with the gallbladder?

    <p>Murphy's sign</p> Signup and view all the answers

    Upon observing that the client is in significant pain post-surgery, which action should the nurse prioritize?

    <p>Ask the client to describe her pain location and intensity.</p> Signup and view all the answers

    How many mL of Morphine Sulfate should the nurse administer for a dose of 6 mg when it is available in 10 mg/1 mL vials?

    <p>0.6 mL</p> Signup and view all the answers

    Which finding provides the best indication of the effectiveness of the pain medication postoperatively?

    <p>The client states a lessening of her pain.</p> Signup and view all the answers

    In assessing the client for pain following gallbladder surgery, which symptom would be least indicative of effective pain control?

    <p>Reports of ongoing severe discomfort</p> Signup and view all the answers

    When determining the priority action following the client's report of extensive pain post-surgery, which assessment should the nurse conduct first?

    <p>Conduct a comprehensive pain assessment.</p> Signup and view all the answers

    Which of the following actions should the nurse take if the client has not passed gas postoperatively?

    <p>Assess the client for bowel sounds.</p> Signup and view all the answers

    Which question could the nurse ask to identify triggers for heartburn?

    <p>Can you identify which spicy foods cause a problem?</p> Signup and view all the answers

    What initial action should the nurse take before commencing an abdominal assessment?

    <p>Encourage the client to empty her bladder.</p> Signup and view all the answers

    Which of the following findings during the abdominal inspection indicates a need for immediate action?

    <p>Marked visible peristalsis.</p> Signup and view all the answers

    When assessing bowel movements, which information should the nurse prioritize?

    <p>Frequency and consistency of bowel movements.</p> Signup and view all the answers

    What should the nurse inquire about to gather important history for abdominal conditions?

    <p>Do you have a history of any abdominal conditions or surgeries?</p> Signup and view all the answers

    In what order should the nurse perform the steps of an abdominal assessment?

    <p>Inspection, auscultation, percussion, palpation.</p> Signup and view all the answers

    Which follow-up question is best to ask about family history concerning dietary issues?

    <p>Does anyone in your family have problems with spicy food?</p> Signup and view all the answers

    Which action should a nurse avoid when preparing a client for an abdominal assessment?

    <p>Instructing the client to keep her arms at her sides.</p> Signup and view all the answers

    What should the nurse prioritize when providing verbal instructions about client positioning to the UAP?

    <p>Documentation of the instructions in the notes.</p> Signup and view all the answers

    What type of precaution is recommended for a client based on their wound culture results?

    <p>Contact precautions.</p> Signup and view all the answers

    Which piece of equipment is most appropriate for assessing the length of a wound tract?

    <p>Sterile tape measure.</p> Signup and view all the answers

    Which irrigation technique is considered the most effective for wound care?

    <p>Irrigating gently with a 60-mL bulb syringe.</p> Signup and view all the answers

    What is the primary goal of using a specific type of dressing in wound care?

    <p>To enhance the healing process of tissue.</p> Signup and view all the answers

    How many mL of linezolid suspension should the nurse administer for a 400 mg dose?

    <p>20 mL.</p> Signup and view all the answers

    What is the total daily dosage of linezolid in mg that the client will receive?

    <p>800 mg.</p> Signup and view all the answers

    Which member of the interdisciplinary team should the nurse collaborate with to address discrepancies in medication orders?

    <p>The pharmacist.</p> Signup and view all the answers

    What should the nurse focus on when obtaining specific information from a client regarding their health problem?

    <p>Closed-ended questions concerning signs and symptoms</p> Signup and view all the answers

    How many 5 mg tablets of metolazone should the nurse administer if the prescription is for 7.5 mg?

    <p>1 1/2 tablets</p> Signup and view all the answers

    When a client describes their pain as 'miseries', what should the nurse prioritize in their assessment?

    <p>Inquire about the source and type of pain</p> Signup and view all the answers

    If a nurse finds a client's fingers blue due to a wrist restraint, what is the immediate action to take?

    <p>Loosen the wrist restraint</p> Signup and view all the answers

    Upon observing a male client remove the covering from an ice pack on his knee, what is the most appropriate first action for the nurse?

    <p>Check for signs of frostbite</p> Signup and view all the answers

    Which factor is least relevant when considering cultural assessments of pain in African-American clients?

    <p>Identifying the emotional state of the client</p> Signup and view all the answers

    In case of wrist restraints showing cyanosis, which of the following actions is NOT a priority?

    <p>Document the incident</p> Signup and view all the answers

    If a grandmother refers to her grandson's pain as 'miseries,' what should be the nurse's subsequent focus?

    <p>Assess detailed pain characteristics</p> Signup and view all the answers

    What should a client with allergies do when the pollen count is high?

    <p>Wear a mask when exposed to dust or pollen.</p> Signup and view all the answers

    How many capsules of Dantrolene should be administered if the prescribed dose is 0.1 grams?

    <p>1 capsule</p> Signup and view all the answers

    What measurement should the nurse expect to assess using a goniometer on a client with osteoarthritis?

    <p>Degree of flexion and extension of the joint</p> Signup and view all the answers

    If a client has received 15 mg of aripiprazole and needs a total daily dose of 30 mg, how many tablets should the nurse administer?

    <p>1 additional tablet</p> Signup and view all the answers

    Which of the following is essential for the proper use of an inhaler?

    <p>Priming the inhaler before the first use.</p> Signup and view all the answers

    What type of actions should a nurse recommend to a client to limit exposure to allergens?

    <p>Cover windows and doors during high pollen seasons.</p> Signup and view all the answers

    If a patient is experiencing spasticity due to multiple sclerosis and has been prescribed Dantrolene, what nursing action is crucial?

    <p>Monitor muscle strength and tone.</p> Signup and view all the answers

    What is the primary purpose of keeping track of the pollen count for a client with allergies?

    <p>To determine when to stay indoors and limit exposure.</p> Signup and view all the answers

    What statement from the client's focused interview could relate to abnormal inspection findings?

    <p>Change in body mass index (BMI)</p> Signup and view all the answers

    Where should abdominal auscultation ideally commence?

    <p>Right upper quadrant (RUQ)</p> Signup and view all the answers

    What action should the nurse take after observing high-pitched gurgling sounds in the right lower abdomen?

    <p>Continue auscultating in the right lower quadrant</p> Signup and view all the answers

    A nurse hears a swishing sound during an abdominal assessment. In which area is this sound likely located?

    <p>Epigastric area</p> Signup and view all the answers

    What is the appropriate response if no venous sounds are detected during an abdominal assessment?

    <p>Note it as a normal finding</p> Signup and view all the answers

    If the nurse percusses over the suprapubic area and hears a dull sound, what should they assess next?

    <p>Palpate for bladder distention</p> Signup and view all the answers

    What information is crucial to gather during the focused interview that could relate to abdominal issues?

    <p>Recent dietary changes</p> Signup and view all the answers

    What assessment technique is essential if bowel sounds are audible at each auscultation location?

    <p>Document the presence of normal bowel sounds</p> Signup and view all the answers

    What action will best help the nurse confirm the presence of an S3 heart sound?

    <p>Use the bell of the stethoscope to continue listening at the apical site.</p> Signup and view all the answers

    What assessment should the nurse perform after determining the client has an S3 heart sound?

    <p>Check for jugular vein distention.</p> Signup and view all the answers

    Which position should the client be placed in to best inspect for jugular vein distention?

    <p>Fowler's position with head straight.</p> Signup and view all the answers

    What should the nurse do next after observing a pulsation low and laterally on the neck?

    <p>Use a stethoscope to auscultate the pulsation.</p> Signup and view all the answers

    How should the nurse begin the carotid artery assessment?

    <p>Palpate one artery while listening to the other side with a stethoscope.</p> Signup and view all the answers

    How would the nurse interpret the finding of a carotid pulse volume assessed as +2?

    <p>The pulse is normal and indicates adequate perfusion.</p> Signup and view all the answers

    What is the significance of not hearing a carotid bruit during assessment?

    <p>It suggests the absence of significant carotid artery stenosis.</p> Signup and view all the answers

    What is the most appropriate action for the nurse if a pulsation is observed but not palpated?

    <p>Use a Doppler ultrasound for more accurate assessment.</p> Signup and view all the answers

    What is the primary purpose of using saline or other prescribed solutions with dressings?

    <p>To promote moisture retention and facilitate healing</p> Signup and view all the answers

    What should be done with excess solution when applying a dressing?

    <p>Wring it out to prevent over-saturation of the dressing</p> Signup and view all the answers

    Which step is essential before covering a wound with a dry dressing?

    <p>Ensuring that the dressing contacts the wound directly</p> Signup and view all the answers

    What is the recommended method for layering gauze when using it on a wound?

    <p>Follow manufacturer's instructions for specific layering techniques</p> Signup and view all the answers

    What is the correct procedure for applying a secondary dressing over a primary dressing?

    <p>Secure it tightly to avoid any movement</p> Signup and view all the answers

    When preparing a dressing for application, which action is most critical to achieve effective wound contact?

    <p>Unfolding the dressing to its full length without any creases</p> Signup and view all the answers

    What technique should be avoided when covering a wound with a dressing?

    <p>Using excessive dressing tape to secure the edges</p> Signup and view all the answers

    What should be the first consideration when selecting a dressing type for a wound?

    <p>The healing requirements of the specific wound</p> Signup and view all the answers

    What should a client with allergies do to minimize exposure to allergens?

    <p>Wear a mask when exposed to dust or pollen.</p> Signup and view all the answers

    How many Dantrolene capsules should a nurse administer for a prescribed dose of 0.1 grams?

    <p>1 capsule</p> Signup and view all the answers

    Which observation is expected when using a goniometer to assess a client's joint?

    <p>Degrees of flexion and extension of the knee joint.</p> Signup and view all the answers

    What is the correct amount of additional aripiprazole tablets a nurse should give a client who has already received 15 mg after the dosage is increased to 30 mg?

    <p>1 tablet</p> Signup and view all the answers

    Which best describes the approach a nurse should take when teaching a client about using an inhaler?

    <p>Teach the client to shake the inhaler before each use.</p> Signup and view all the answers

    When should a nurse expect to see improvement in a client’s symptoms after administering an inhaler?

    <p>Immediately after the client inhales.</p> Signup and view all the answers

    What potential effect should a nurse monitor for in a patient taking Dantrolene for spasticity management?

    <p>Increased risk of liver dysfunction.</p> Signup and view all the answers

    Which factor should a nurse consider while advising a client with allergies about clothing choices?

    <p>Fabrics that cause itching should be avoided, regardless of washing.</p> Signup and view all the answers

    Which of the following foods is not considered a potassium-rich food?

    <p>Chicken breast</p> Signup and view all the answers

    What should the nurse do first when realizing the prescribed dose of hydrochlorothiazide is different from the available tablet strength?

    <p>Observe the tablet to see if it is scored</p> Signup and view all the answers

    What identifier is least acceptable for the nurse to use when verifying client identity prior to medication administration?

    <p>Physical location</p> Signup and view all the answers

    Which of the following is a sign of fluid volume deficit that the nurse must educate the client about?

    <p>Tenting on arm when checking skin turgor</p> Signup and view all the answers

    What is the highest priority nursing problem for a client recovering from a stroke?

    <p>Aspiration</p> Signup and view all the answers

    When taking action to prevent a client from aspirating, what should the nurse do first?

    <p>Elevate the head of the bed to 45 degrees</p> Signup and view all the answers

    What is the most appropriate explanation for the necessity of client identification checks before medication administration?

    <p>This is a double-check to ensure that no errors occur</p> Signup and view all the answers

    Which symptom is most indicative of fluid volume deficit in an older adult?

    <p>Longitudinal furrows on the tongue</p> Signup and view all the answers

    What is the most appropriate response for a nurse when a client is reluctant to discuss their surgical procedure?

    <p>Encouraging the client to express their feelings about the surgery.</p> Signup and view all the answers

    How many teaspoons should be administered when metoclopramide is prescribed as 10 mg and the available concentration is 5 mg/5 ml?

    <p>2 teaspoons</p> Signup and view all the answers

    Which position is safest for a client receiving a feeding through a gastrostomy tube?

    <p>Fowler's position</p> Signup and view all the answers

    Which questioning technique is most effective for a nurse to use when gathering information about a client's health problem during an admission interview?

    <p>Open-ended questions</p> Signup and view all the answers

    What critical information should be considered when positioning an unresponsive client for feeding through a gastrostomy tube?

    <p>Utilizing a semi-sitting position to reduce aspiration risk.</p> Signup and view all the answers

    What is a significant risk associated with performing feeds in a supine position?

    <p>Increased risk of aspiration</p> Signup and view all the answers

    What action should a nurse take if a client refuses to discuss their experiences after a mastectomy?

    <p>Respect the client's wishes and give them space.</p> Signup and view all the answers

    When calculating medication dosages, what formula should the nurse use?

    <p>Desired dose / Dose on hand x Volume on hand</p> Signup and view all the answers

    Which interprofessional team member should the nurse consult to address the client's swallowing difficulties related to dysphagia?

    <p>Speech Therapist</p> Signup and view all the answers

    What should be the nurse's primary instruction to the UAP when assisting a client with dysphagia during meal times?

    <p>Ensure the client is in a high Fowler's position during and after meals</p> Signup and view all the answers

    Which action should the nurse implement to best support the client's nutritional status given the dysphagia precautions?

    <p>Advise the UAP to thicken all liquids per the dietician’s orders</p> Signup and view all the answers

    What symptom indicates a potential nutritional deficiency that the nurse should investigate further?

    <p>Pale conjunctivae indicating possible anemia</p> Signup and view all the answers

    What type of diet modification is suggested for a client with dysphagia to ensure safe eating?

    <p>A pureed diet with honey-thickened liquids</p> Signup and view all the answers

    If the client exhibits dry and cracked lips, what should the nurse prioritize in the assessment?

    <p>Investigate for potential dehydration or nutritional deficiency</p> Signup and view all the answers

    What is the nurse's role regarding meals for a client who requires both occupational therapy and dysphagia precautions?

    <p>Coordinate with the UAP to follow therapy guidelines while assisting the client</p> Signup and view all the answers

    In which situation would the nurse need to reassess the client's nutrient intake?

    <p>When clinical signs of malnutrition are present</p> Signup and view all the answers

    What is the most appropriate pain scale to assess the intensity of the client's pain?

    <p>Numeric pain scale</p> Signup and view all the answers

    After noting the client's symptoms of dyspnea, dizziness, and chest discomfort, what should be the nurse's immediate assessment action?

    <p>Place the client in a supine position to monitor orthopnea</p> Signup and view all the answers

    What is the best approach for the nurse to confirm the client's heart rate after detecting an irregular pulse?

    <p>Auscultate the apical pulse for 1 full minute</p> Signup and view all the answers

    To effectively gather subjective data regarding the client's history of chest pain, how should the nurse start?

    <p>Encourage the client to describe his chest discomfort</p> Signup and view all the answers

    Given the client's report of chest pressure that stops upon resting, what is the most relevant nursing consideration?

    <p>Evaluate the timing and duration of symptom occurrence</p> Signup and view all the answers

    What nursing action should be taken immediately when the client exhibits an irregular apical rate?

    <p>Place the client on a cardiac telemetry monitor</p> Signup and view all the answers

    Which statement best encompasses the implications of the client's symptoms of tiredness and chest pressure?

    <p>Client's symptoms may indicate an underlying chronic condition</p> Signup and view all the answers

    What is the primary goal when assessing a client's pain levels in a clinical setting?

    <p>To establish an effective pain management plan</p> Signup and view all the answers

    What is a common symptom of hypophosphatemia?

    <p>Bone pain</p> Signup and view all the answers

    Which condition is associated with hypernatremia?

    <p>Myoclonic jerks</p> Signup and view all the answers

    What is the primary reason for collecting a 24-hour urine sample?

    <p>To assess kidney function</p> Signup and view all the answers

    How should a face mask be used according to current guidelines?

    <p>As a product that covers the wearer's nose and mouth for source control</p> Signup and view all the answers

    What distinguishes an N95 respirator from a regular face mask?

    <p>Designed to fit tightly to the face</p> Signup and view all the answers

    Which of the following is a symptom of hyponatremia?

    <p>Nausea</p> Signup and view all the answers

    What instructions should be followed before starting a 24-hour urine collection?

    <p>Empty the bladder before the first collection</p> Signup and view all the answers

    Which condition is likely to cause hyperchloremia?

    <p>Vomiting</p> Signup and view all the answers

    What should be the primary advice for a client with allergies regarding high pollen count days?

    <p>Wear a face mask and stay indoors.</p> Signup and view all the answers

    How is the dosage of Dantrolene prescribed for a client with spasticity indicated in grams converted for administration?

    <p>0.1 grams per dose.</p> Signup and view all the answers

    When using a goniometer for measuring a client's knee joint flexion, which measurement should the nurse anticipate?

    <p>Degrees of flexion and extension.</p> Signup and view all the answers

    If a daily prescription for aripiprazole is increased from 15 mg to 30 mg, how many additional tablets are needed after one has been taken?

    <p>1 tablet.</p> Signup and view all the answers

    What is the most appropriate method for measuring body fat precisely in a clinical setting?

    <p>Underarm skinfold calipers.</p> Signup and view all the answers

    What device is NOT appropriate for assessing the degree of joint movement during physical assessment?

    <p>Calipers.</p> Signup and view all the answers

    Which of the following is the best practice for a nurse teaching proper inhaler use?

    <p>Exhale fully to empty the lungs before inhaling medication.</p> Signup and view all the answers

    Which factor can significantly undermine the effectiveness of an inhaler when used by a client?

    <p>Improper timing of inhalation upon drug delivery.</p> Signup and view all the answers

    What is a consequence of using a hydrocolloid dressing for wound care?

    <p>It can create excessive moisture if not monitored.</p> Signup and view all the answers

    What is the recommended maximum wear time for a hydrocolloid dressing?

    <p>7 days</p> Signup and view all the answers

    Which of the following is a primary function of hydrocolloid dressings?

    <p>They limit shear and provide a dry cover.</p> Signup and view all the answers

    What happens if the seal of a hydrocolloid dressing breaks?

    <p>It may compromise wound healing and increase exposure.</p> Signup and view all the answers

    In what scenario is it inappropriate to use a hydrocolloid dressing?

    <p>On a wound that has moderate to heavy drainage.</p> Signup and view all the answers

    How does a hydrocolloid dressing contribute to wound healing?

    <p>By providing a moist environment that supports cellular migration.</p> Signup and view all the answers

    Which characteristic is NOT true about hydrocolloid dressings?

    <p>They are completely transparent.</p> Signup and view all the answers

    What important aspect should be managed alongside the use of hydrocolloid dressings?

    <p>The moisture levels to prevent excessive drainage.</p> Signup and view all the answers

    What is the primary nursing action to help a client adapt to the appearance of a stoma?

    <p>Reassure the client about the stoma's appearance over time.</p> Signup and view all the answers

    Which method is considered the most reliable for confirming the proper placement of a nasogastric tube?

    <p>Obtaining a chest x-ray after insertion.</p> Signup and view all the answers

    When addressing a young mother's increase in anxiety, which area should the nurse prioritize obtaining information about first?

    <p>Nutritional history to identify dietary causes.</p> Signup and view all the answers

    Which advice should the nurse emphasize for a client with multiple allergies?

    <p>All clothing should be either new or freshly washed before use.</p> Signup and view all the answers

    What is a common misconception about the presentation of a stoma following surgery?

    <p>The stoma will maintain its initial size regardless of postoperative care.</p> Signup and view all the answers

    What should the nurse avoid when preparing to teach a client with allergies about managing exposure?

    <p>Downplaying the significance of pollen counts relevant to outdoor allergies.</p> Signup and view all the answers

    In the context of reducing anxiety during a physical exam, which of these factors should be explored last?

    <p>Financial stressors and their impact.</p> Signup and view all the answers

    What critical insight should the nurse convey to a client about the changes in stoma size post-surgery?

    <p>Initial swelling is temporary and will reduce over time.</p> Signup and view all the answers

    What is the most appropriate fluid intake recommendation for a patient with dark amber urine indicating fluid volume deficit?

    <p>Advise to drink any type of juice.</p> Signup and view all the answers

    Which vital sign change is most likely when a patient with fluid volume deficit changes position?

    <p>A decrease in blood pressure.</p> Signup and view all the answers

    When assessing for orthostatic vital sign changes, which action should the nurse prioritize first?

    <p>Position the patient in a supine position.</p> Signup and view all the answers

    After obtaining the first blood pressure reading, what should the nurse do next?

    <p>Assess for an auscultatory gap.</p> Signup and view all the answers

    Which assessment data is most critical for ongoing evaluation of a patient's fluid volume status?

    <p>Body weight.</p> Signup and view all the answers

    What is the best course of action if a nurse notes inelastic skin turgor during an assessment?

    <p>Document the presence of inelastic skin turgor.</p> Signup and view all the answers

    What potential complication is associated with a patient on hydrochlorothiazide who displays signs of fluid volume deficit?

    <p>Electrolyte imbalance.</p> Signup and view all the answers

    What fluid characteristic most clearly indicates that a patient has a fluid volume deficit?

    <p>Dark amber and concentrated urine.</p> Signup and view all the answers

    Study Notes

    Fluid Volume Deficit

    • Donna King is an 80-year-old female admitted with fluid volume deficit
    • Donna is taking hydrochlorothiazide, a diuretic, which can contribute to fluid volume deficit
    • Donna is experiencing orthostatic vital sign Changes as can be seen with fluid volume deficit

    Vital Sign Changes

    • Decreased blood pressure is a sign of fluid volume deficit when changing positions
    • When assessing for orthostatic vital sign changes, the nurse should position Donna in a supine position first
    • The nurse assesses for an auscultatory gap after taking the first blood pressure measurement

    Assessment for Fluid Volume Deficit

    • Urine color is key in assessing for fluid volume deficit

    Dysphagia

    • Donna experiences dysphagia, which can impact her fluid and nutritional status
    • The speech therapist determines that Donna needs dysphagia precautions, including a pureed diet and honey-thickened liquids

    Nursing Care for Dysphagia

    • The nurse should bathe the client first then assist with a meal in high Fowler's position
    • All liquids should be thickened per orders to manage dysphagia

    Nutritional Assessment

    • Pale conjunctivae, rough, dry, scaly, and pale skin are signs of altered nutrition

    Continuous Feeding

    • The client is ordered to receive continuous feeding, which is later changed to bolus feeding
    • The nurse should ensure the client and spouse are ready to learn how to manage continuous feeding before discharge

    Bolus Feeding

    • The nurse observes the spouse administering a bolus feeding to the client
    • The spouse should hold the syringe upright while the feeding enters the stomach
    • The tubing should be flushed with water after the syringe is empty

    Stage 1 Pressure Injury

    • Stage 1 pressure injury is present with the presence of non-blanchable erythema of intact skin.
    • The nurse should document the drainage as serous

    Pressure Injury Care

    • Transparent film dressing can be used for stage 1 pressure injuries
    • The nurse should implement interventions to reduce the effects of moisture on the client's skin.
    • Avoid moist heat to the area following exposure to feces.

    Wound Care Dressings

    • Hydrocolloid dressings are used for wound management.
    • Hydrocolloid dressings can be used for up to 7 days at a time.
    • Hydrocolloid dressings are used to protect wounds and absorb moisture.
    • Calcium alginate dressings are used for wound management.
    • Calcium alginate dressings are used to absorb moisture when there is significant exudate from the wound.
    • Gauze dressings are used for wound management.

    Hospice Care

    • Hospice care is available for terminally ill patients.
    • Hospice teams provide 24/7 support.
    • Hospice strives to ensure death with dignity.

    Pneumonia

    • Oxygen saturation below 90% is considered inadequate
    • Ambulating a patient with pneumonia can lower oxygen saturation and increase respiratory effort.

    Nursing Assessment

    • Before planning care, the nurse will determine the problem's etiology.
    • This will help determine the goal, plan of care and prioritize the interventions.

    Azithromycin (Zithromax)

    • Azithromycin is available in 250 mg scored tablets.
    • For a prescribed dose of 500 mg, 2 tablets would be administered per dose.

    Colostomy

    • After surgery, a client may have concerns about the size and appearance of their colostomy.
    • It is important to provide reassurance and support.

    Abdominal Assessment

    • Encourage the client to empty their bladder prior to assessing the abdomen.
    • Place a pillow under the client's knees to promote relaxation.
    • Ask about the client's pain location.
    • Instruct the client to place their hands over their head.
    • Discuss the abdominal assessment's sequence of steps.

    Abdominal Assessment Sequence

    • Inspection
    • Auscultation
    • Percussion
    • Palpation

    Abdominal Inspection

    • Observe for symmetry, bulges, masses, umbilicus position, rashes, striae, scars, visible pulsations and peristalsis.

    Abdominal Findings

    • Rebound tenderness and involuntary abdominal rigidity may indicate appendicitis.

    Murphy's Sign

    • Murphy's sign is a test that is used to help in the diagnosis of cholecystitis.

    Post-Operative Pain

    • Post-operative pain is common.
    • Assess the client's pain, location, intensity, and observe for non-verbal cues.

    Morphine Sulfate

    • A 6 mg dose of Morphine sulfate IV push would require 0.6 mL.

    Post-Operative Pain Management

    • Monitor the client's response to pain medications.
    • Observe the client's vital signs, physical appearance, and statements.

    Client Privacy

    • Maintain client confidentiality.
    • Provide consistent care by clearly communicating with the team.

    Wound Culture

    • Contact precautions should be used for clients with confirmed MRSA infections.

    Wound Tract Assessment

    • Sterile gloves and lubricant are needed to assess wound tract length.

    Wound Irrigation

    • Use sterile saline and a bulb syringe to irrigate wounds gently.

    Wound Dressing

    • A moist wound dressing facilitates tissue healing.

    Linezolid (Zyvox)

    • An antibiotic used to treat infections.
    • It interferes with bacterial protein production needed for multiplication.
    • A suspension of 400 mg every 12 hours for 14 days is a common dosage.
    • The medication is supplied as 100mg/5 mL.
    • A 400mg dose would require 20mL of medication.
    • The total daily dosage is 800mg.

    Medication Discrepancies

    • Collaborate with the pharmacist to resolve medication discrepancies.

    Wound Care

    • Clean wounds with normal saline, or another prescribed solution
    • Wet dressings should be wrung out to remove excess liquid
    • Make sure the dressing makes contact with the wound
    • Cover wet dressing with a dry one
    • Secure the dressing with tape

    Allergies

    • Limit client's exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes
    • Encourage client to wear a mask when working around dust or pollen
    • Avoid clothing that causes itching

    Dantrolene

    • Dantrolene (Dantrium) is prescribed for spasticity
    • Available in 100 mg capsules
    • 0.1 grams = 100 mg
    • 100 mg = 1 capsule

    Goniometer

    • Used to measure joint flexion and extension in degrees

    Aripiprazole (Abilify)

    • Available in 15 mg tablets
    • 30 mg (total) - 15 mg (already received) = 15 mg remaining

    Inhaler Use

    • Instruct client to use inhaler according to manufacturer instructions

    Closed-Ended Questions

    • Used to obtain specific information on common signs and symptoms of a client's health problem

    Metolazone (Zaroxolyn)

    • Available in 5 mg tablets
    • 7.5 mg (desired) / 5 mg (available) = 1.5 tablets

    African-American Culture

    • "Misery" refers to pain

    Wrist Restraints

    • Loosen restraints if fingers are blue

    Ice Pack

    • Observe skin under ice pack

    Abdominal Inspection

    • Observe client's abdomen
    • Note any distention, masses, or scars
    • Note contour, symmetry, or pulsations

    Focused Interview

    • Questions regarding bowel movements, previous surgeries, nausea, vomiting, food intolerance, and change in body mass index

    Abdominal Auscultation

    • Start with the right lower quadrant (RLQ)

    Normal Bowel Sounds

    • 8 to 20 sounds per minute in all quadrants

    Abdominal Vascular Sounds

    • Soft, low-pitched, and continuous
    • Not considered abnormal

    Percussion

    • Dull sound over the suprapubic area may indicate a full bladder

    S3 Heart Sound

    • Dull, low-pitched sound
    • Heard during early diastole
    • Can indicate heart failure
    • Reassess for jugular vein distention

    Jugular Veins

    • Observe for pulsations in the neck

    Carotid Artery Assessment

    • Palpate one artery at a time
    • Avoid palpating both simultaneously
    • Listen for carotid bruit (swishing sound)
    • +2 volume is normal
    • Absence of bruit is normal

    Allergies

    • Clients with allergies should minimize exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes.
    • Clients with allergies should wear a mask when working around dust or pollen.
    • Clients with allergies should avoid clothing that causes itching.

    Dantrolene (Dantrium) for Spasticity

    • 0.1 grams PO bid is equivalent to one 100 mg capsule of Dantrolene.

    Goniometer

    • A goniometer measures the degree of flexion and extension of joints.

    Aripiprazole (Abilify) Dosage

    • A client prescribed 30 mg daily of Aripiprazole, who has already received 15 mg, needs an additional 15 mg; this is equivalent to one 15 mg tablet.

    Inhaler Use

    • Clients should administer inhaled medication promptly after removing the inhaler from its container.

    Dealing with a Reluctant Client

    • When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should acknowledge their feelings and offer their presence when the client is ready.

    Metoclopramide (Reglan) for Hiccups

    • A client with hiccups prescribed Metoclopramide 10 mg PO q 6 hours should receive 2 teaspoons of the medication.

    Gastrostomy Tube (GT) Feeding

    • Clients with a GT should be placed in a semi-sitting (Fowler's) position during feeding to reduce the risk of aspiration.

    Gathering Client Information

    • When assessing a client's signs and symptoms, open-ended questions are more effective than closed-ended questions.

    Potassium-Rich Foods

    • Potassium-rich foods include baked potato, green beans, grapefruit juice, and chicken breast.

    Medication Administration: Oral Tablets

    • When a nurse is administering oral tablets, it is essential to verify the correct dosage and availability of scored tablets.

    Client Identification

    • It is hospital policy to always check client identification before administering medication or treatment.

    Client Identifiers

    • Acceptable client identifiers include:
      • Full name
      • Date of birth
      • Physical location
      • Room number

    Fluid Volume Deficit

    • The nurse should educate clients about signs and symptoms of fluid volume deficit, including:
      • Changes in mental status
      • Changes in urine output
      • Tenting on arm when checking skin turgor
      • Presence of tachycardia
      • Longitudinal furrows on the tongue

    Highest Nursing Priority

    • In a client recovering from a stroke with a history of dysphagia, aspiration is the highest priority problem.

    Preventing Aspiration

    • To prevent aspiration, the nurse should:
      • Elevate the head of the bed to 45 degrees.
      • Ensure the client's meals are pureed.

    Collaboration with Speech Therapist

    • The nurse should consult with the speech therapist when a client exhibits dysphagia.

    Dysphagia Precautions

    • Clients at risk for aspiration should be instructed to:
      • Eat pureed foods.
      • Drink honey-thickened liquids.

    UAP Instructions

    • The UAP should:
      • Elevate the head of the bed to 45 degrees during and after the meal.
      • Assist with the meal before bathing or changing bed linens.

    Intervention for Dysphagia Precautions

    • The nurse should instruct the UAP to add a thickening agent to all liquids according to orders.

    Altered Nutrition

    • Indicators of altered nutrition include:
      • Pale conjunctivae
      • Smooth, thick finger and toe nails
      • Rough, dry, scaly, and pale skin
      • Flat abdomen, painful to palpate
      • Dry and cracked lips

    Pain Assessment Scale

    • For assessing client pain, the Faces Pain scale is the most appropriate for clients experiencing dysphagia.

    Cardiovascular Assessment: Dyspnea, Dizziness, Chest Discomfort

    • When a client reports increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, the nurse should:
      • Ask the client to stand and then recheck the blood pressure.
      • Place the client in a supine position and observe for orthopnea.
      • Determine if the client is currently experiencing any angina.

    Assessing Irregular Pulse Rhythm

    • To confirm an irregular pulse rhythm, the nurse should auscultate the apical pulse for 1 minute.

    Gathering Subjective Data: Chest Pain

    • To gather data about a client's history of chest pain, the nurse should encourage the client to describe their chest discomfort.

    ### Electrolyte Imbalances

    • Hypomagnesemia is associated with muscle weakness, twitches, tremors, irritability, insomnia, and drowsiness.
    • Hyperchloremia can cause diarrhoea and vomiting.
    • Hypochloremia can also cause diarrhoea and vomiting.
    • Hyperphosphatemia can lead to osteoporosis and cardiovascular disease.
    • Hypophosphatemia can cause changes in mental state, bone pain, fragility, fatigue, weight loss, and weakness.
    • Hypernatremia can cause lethargy, myoclonic jerks, confusion, nystagmus, and tachycardia.
    • Hyponatremia can cause nausea, vomiting, lethargy, seizures, and neurological deficits.

    24 Hour Urine Sample

    • Purpose: To measure the amount of protein or other substances in the urine and check kidney function.
    • Instructions:
      • Empty the bladder in the morning. This is the start time.
      • Collect all urine in a special container for the next 24 hours, including urine from bowel movements.
      • On the second day,empty the bladder 10 minutes before or after the same time as the first void the previous day.
      • Store the container in the refrigerator or cool place.
      • Label the container with name, date, and time of completion.
      • Return to the lab immediately.

    Face Mask vs. Respirator Mask

    • N95 Respirators are designed to achieve a very close facial fit and filter airborne particles efficiently.
    • The edges of the respirator are designed to form a seal around the nose and mouth.
    • Face masks cover the nose and mouth. They are used for source control by the general public and healthcare personnel.
    • Surgical N95 Respirators are used commonly in healthcare settings and are a subset of N95 Filtering Facepiece Respirators (FFRs).

    Wound Care

    • Hydrocolloid dressings do not allow visual assessment and are not used in the presence of excessive moisture.
    • Transparent dressings allow visualisation of wound healing. They are used for pressure redistribution, bed or chair cushion, and are not used in the presence of excessive moisture.
    • Clean site dressings help to limit shear, promote epithelialization and manage incontinence. They are changed when the seal of the dressing breaks, and the maximal wear time is seven days.

    ### Naso Gastric Tube

    • Proper placement of a nasogastric tube is confirmed through a chest x-ray.
    • Aspirating gastric contents to ensure a pH value of less than 4 or less and hearing air pass in the stomach are also methods used to assess placement but not as reliable as an x-ray.

    Client with Multiple Sclerosis

    • Dantrolene (Dantrium) is available in 100 mg capsules and is prescribed 0.1 grams (100 mg) twice daily.
    • The nurse should administer 1 capsule twice daily.

    ### Assessment of Osteoarthritis

    • Goniometer measures the degree of flexion and extension of a joint, which can be used to assess osteoarthritis.

    ### Fluid Volume Deficit

    • Orthostatic vital sign changes involve taking vital signs while lying down, sitting, and then standing to assess for a drop in blood pressure and increase in pulse rate.
    • These changes are a sign of fluid volume deficit.
    • Donna's vital signs are expected to decrease as she changes position.
    • Assess Donna in a supine position first and then assess for an auscultatory gap after taking the initial blood pressure reading.
    • Elastin skin turgor is a sign of fluid deficit and should be documented.
    • Confirm inelastic skin turgor by pinching the skin.
    • Urine colour changes, body weight changes, and skin turgor assessment allow ongoing evaluation of fluid volume status.
    • Donna's daughter's report of Donna's usual weight provides a baseline for assessing her hydration status.
    • Encourage Donna to increase fluid intake.

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