Podcast
Questions and Answers
What is the maximum wear time for a hydro colloid dressing?
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?
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?
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?
Which type of dressing is used to protect a wound from environmental damage?
What is the primary function of gauze dressings?
What is the primary function of gauze dressings?
What is the most appropriate action for the nurse regarding the feeding rate?
What is the most appropriate action for the nurse regarding the feeding rate?
Which crucial information should the nurse collect before discharge instructions?
Which crucial information should the nurse collect before discharge instructions?
How should the nurse proceed when the spouse is emotional during equipment demonstration?
How should the nurse proceed when the spouse is emotional during equipment demonstration?
When observing the spouse administering a bolus feeding, what should the nurse do?
When observing the spouse administering a bolus feeding, what should the nurse do?
What should be the initial nursing action when administering bolus feeding?
What should be the initial nursing action when administering bolus feeding?
What is a priority when the spouse demonstrates administering feeding?
What is a priority when the spouse demonstrates administering feeding?
What strategy is essential before transitioning to bolus feedings?
What strategy is essential before transitioning to bolus feedings?
In the context of nutrition education, what should the nurse emphasize most?
In the context of nutrition education, what should the nurse emphasize most?
What is the most appropriate action for the nurse to take for the client's inflamed areas?
What is the most appropriate action for the nurse to take for the client's inflamed areas?
Which factor is the most accurate etiology for the client's condition?
Which factor is the most accurate etiology for the client's condition?
In the care plan for the client, which goal should the nurse prioritize?
In the care plan for the client, which goal should the nurse prioritize?
To provide effective pressure relief at night, which position should the nurse advise the client to adopt?
To provide effective pressure relief at night, which position should the nurse advise the client to adopt?
What should the nurse reinforce regarding the use of a pressure-reducing gel cushion?
What should the nurse reinforce regarding the use of a pressure-reducing gel cushion?
For a stage 1 pressure injury (PI), which dressing is most appropriate?
For a stage 1 pressure injury (PI), which dressing is most appropriate?
In documenting wound drainage, which term should the nurse use for clear fluid?
In documenting wound drainage, which term should the nurse use for clear fluid?
What is the best intervention for reducing moisture's impact on the client’s skin?
What is the best intervention for reducing moisture's impact on the client’s skin?
What characteristic of urine suggests a fluid volume deficit in a patient?
What characteristic of urine suggests a fluid volume deficit in a patient?
Which liquid is most beneficial for a patient with fluid volume deficit?
Which liquid is most beneficial for a patient with fluid volume deficit?
When assessing for orthostatic vital sign changes, what is the nurse's first action?
When assessing for orthostatic vital sign changes, what is the nurse's first action?
What is a critical indicator of fluid volume status in this patient?
What is a critical indicator of fluid volume status in this patient?
What should the nurse do after recording the initial blood pressure measurement?
What should the nurse do after recording the initial blood pressure measurement?
Which finding would suggest worsening fluid volume deficit in the patient?
Which finding would suggest worsening fluid volume deficit in the patient?
Donna is prescribed hydrochlorothiazide. What is the primary concern related to this medication?
Donna is prescribed hydrochlorothiazide. What is the primary concern related to this medication?
Which symptom is least likely associated with fluid volume deficit?
Which symptom is least likely associated with fluid volume deficit?
Which member of the interprofessional team should the nurse obtain an order from to address the client's nutritional challenges?
Which member of the interprofessional team should the nurse obtain an order from to address the client's nutritional challenges?
When seeking consultation for dysphagia issues, which interprofessional team member should the nurse approach?
When seeking consultation for dysphagia issues, which interprofessional team member should the nurse approach?
What is the most appropriate instruction for the nurse to give the UAP before assisting the client with meals?
What is the most appropriate instruction for the nurse to give the UAP before assisting the client with meals?
In managing dysphagia precautions, which action should the nurse prioritize?
In managing dysphagia precautions, which action should the nurse prioritize?
Which symptom could indicate that the nurse needs to further evaluate the client's nutrition?
Which symptom could indicate that the nurse needs to further evaluate the client's nutrition?
Which clinical sign reflects potential nutritional deficiencies in the client?
Which clinical sign reflects potential nutritional deficiencies in the client?
What could be a critical hydration recommendation for a client with dysphagia?
What could be a critical hydration recommendation for a client with dysphagia?
What common misconception might lead to unsafe feeding practices for a client with dysphagia?
What common misconception might lead to unsafe feeding practices for a client with dysphagia?
What is the primary purpose of using hydrogel dressings on wounds?
What is the primary purpose of using hydrogel dressings on wounds?
In which situation is calcium alginate dressing most appropriately applied?
In which situation is calcium alginate dressing most appropriately applied?
What is a key characteristic of foam dressings regarding their usage?
What is a key characteristic of foam dressings regarding their usage?
What should be evaluated before changing a hydrocolloid dressing?
What should be evaluated before changing a hydrocolloid dressing?
What is a main advantage of using gauze dressings?
What is a main advantage of using gauze dressings?
What is the primary goal of hospice care for patients and families?
What is the primary goal of hospice care for patients and families?
Which description best characterizes the support provided by hospice team members?
Which description best characterizes the support provided by hospice team members?
What immediate action should a nurse take when a client with pneumonia shows a decrease in oxygen saturation?
What immediate action should a nurse take when a client with pneumonia shows a decrease in oxygen saturation?
In the nursing assessment process, after identifying a problem, what should the nurse do next?
In the nursing assessment process, after identifying a problem, what should the nurse do next?
How many azithromycin tablets should a nurse administer per dose if prescribed 500 mg and it's available as 250 mg tablets?
How many azithromycin tablets should a nurse administer per dose if prescribed 500 mg and it's available as 250 mg tablets?
When a client becomes upset after observing their colostomy for the first time, what is the most supportive response from the nurse?
When a client becomes upset after observing their colostomy for the first time, what is the most supportive response from the nurse?
What aspect of hospice care ensures that patients can maintain dignity until death?
What aspect of hospice care ensures that patients can maintain dignity until death?
What critical situation arises when a client experiences oxygen saturation below 90%?
What critical situation arises when a client experiences oxygen saturation below 90%?
What condition might the nurse suspect if a patient exhibits rebound tenderness and involuntary rigidity of the abdomen?
What condition might the nurse suspect if a patient exhibits rebound tenderness and involuntary rigidity of the abdomen?
Which assessment technique is most appropriate to confirm a problem specifically with the gallbladder?
Which assessment technique is most appropriate to confirm a problem specifically with the gallbladder?
Upon observing that the client is in significant pain post-surgery, which action should the nurse prioritize?
Upon observing that the client is in significant pain post-surgery, which action should the nurse prioritize?
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?
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?
Which finding provides the best indication of the effectiveness of the pain medication postoperatively?
Which finding provides the best indication of the effectiveness of the pain medication postoperatively?
In assessing the client for pain following gallbladder surgery, which symptom would be least indicative of effective pain control?
In assessing the client for pain following gallbladder surgery, which symptom would be least indicative of effective pain control?
When determining the priority action following the client's report of extensive pain post-surgery, which assessment should the nurse conduct first?
When determining the priority action following the client's report of extensive pain post-surgery, which assessment should the nurse conduct first?
Which of the following actions should the nurse take if the client has not passed gas postoperatively?
Which of the following actions should the nurse take if the client has not passed gas postoperatively?
Which question could the nurse ask to identify triggers for heartburn?
Which question could the nurse ask to identify triggers for heartburn?
What initial action should the nurse take before commencing an abdominal assessment?
What initial action should the nurse take before commencing an abdominal assessment?
Which of the following findings during the abdominal inspection indicates a need for immediate action?
Which of the following findings during the abdominal inspection indicates a need for immediate action?
When assessing bowel movements, which information should the nurse prioritize?
When assessing bowel movements, which information should the nurse prioritize?
What should the nurse inquire about to gather important history for abdominal conditions?
What should the nurse inquire about to gather important history for abdominal conditions?
In what order should the nurse perform the steps of an abdominal assessment?
In what order should the nurse perform the steps of an abdominal assessment?
Which follow-up question is best to ask about family history concerning dietary issues?
Which follow-up question is best to ask about family history concerning dietary issues?
Which action should a nurse avoid when preparing a client for an abdominal assessment?
Which action should a nurse avoid when preparing a client for an abdominal assessment?
What should the nurse prioritize when providing verbal instructions about client positioning to the UAP?
What should the nurse prioritize when providing verbal instructions about client positioning to the UAP?
What type of precaution is recommended for a client based on their wound culture results?
What type of precaution is recommended for a client based on their wound culture results?
Which piece of equipment is most appropriate for assessing the length of a wound tract?
Which piece of equipment is most appropriate for assessing the length of a wound tract?
Which irrigation technique is considered the most effective for wound care?
Which irrigation technique is considered the most effective for wound care?
What is the primary goal of using a specific type of dressing in wound care?
What is the primary goal of using a specific type of dressing in wound care?
How many mL of linezolid suspension should the nurse administer for a 400 mg dose?
How many mL of linezolid suspension should the nurse administer for a 400 mg dose?
What is the total daily dosage of linezolid in mg that the client will receive?
What is the total daily dosage of linezolid in mg that the client will receive?
Which member of the interdisciplinary team should the nurse collaborate with to address discrepancies in medication orders?
Which member of the interdisciplinary team should the nurse collaborate with to address discrepancies in medication orders?
What should the nurse focus on when obtaining specific information from a client regarding their health problem?
What should the nurse focus on when obtaining specific information from a client regarding their health problem?
How many 5 mg tablets of metolazone should the nurse administer if the prescription is for 7.5 mg?
How many 5 mg tablets of metolazone should the nurse administer if the prescription is for 7.5 mg?
When a client describes their pain as 'miseries', what should the nurse prioritize in their assessment?
When a client describes their pain as 'miseries', what should the nurse prioritize in their assessment?
If a nurse finds a client's fingers blue due to a wrist restraint, what is the immediate action to take?
If a nurse finds a client's fingers blue due to a wrist restraint, what is the immediate action to take?
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?
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?
Which factor is least relevant when considering cultural assessments of pain in African-American clients?
Which factor is least relevant when considering cultural assessments of pain in African-American clients?
In case of wrist restraints showing cyanosis, which of the following actions is NOT a priority?
In case of wrist restraints showing cyanosis, which of the following actions is NOT a priority?
If a grandmother refers to her grandson's pain as 'miseries,' what should be the nurse's subsequent focus?
If a grandmother refers to her grandson's pain as 'miseries,' what should be the nurse's subsequent focus?
What should a client with allergies do when the pollen count is high?
What should a client with allergies do when the pollen count is high?
How many capsules of Dantrolene should be administered if the prescribed dose is 0.1 grams?
How many capsules of Dantrolene should be administered if the prescribed dose is 0.1 grams?
What measurement should the nurse expect to assess using a goniometer on a client with osteoarthritis?
What measurement should the nurse expect to assess using a goniometer on a client with osteoarthritis?
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?
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?
Which of the following is essential for the proper use of an inhaler?
Which of the following is essential for the proper use of an inhaler?
What type of actions should a nurse recommend to a client to limit exposure to allergens?
What type of actions should a nurse recommend to a client to limit exposure to allergens?
If a patient is experiencing spasticity due to multiple sclerosis and has been prescribed Dantrolene, what nursing action is crucial?
If a patient is experiencing spasticity due to multiple sclerosis and has been prescribed Dantrolene, what nursing action is crucial?
What is the primary purpose of keeping track of the pollen count for a client with allergies?
What is the primary purpose of keeping track of the pollen count for a client with allergies?
What statement from the client's focused interview could relate to abnormal inspection findings?
What statement from the client's focused interview could relate to abnormal inspection findings?
Where should abdominal auscultation ideally commence?
Where should abdominal auscultation ideally commence?
What action should the nurse take after observing high-pitched gurgling sounds in the right lower abdomen?
What action should the nurse take after observing high-pitched gurgling sounds in the right lower abdomen?
A nurse hears a swishing sound during an abdominal assessment. In which area is this sound likely located?
A nurse hears a swishing sound during an abdominal assessment. In which area is this sound likely located?
What is the appropriate response if no venous sounds are detected during an abdominal assessment?
What is the appropriate response if no venous sounds are detected during an abdominal assessment?
If the nurse percusses over the suprapubic area and hears a dull sound, what should they assess next?
If the nurse percusses over the suprapubic area and hears a dull sound, what should they assess next?
What information is crucial to gather during the focused interview that could relate to abdominal issues?
What information is crucial to gather during the focused interview that could relate to abdominal issues?
What assessment technique is essential if bowel sounds are audible at each auscultation location?
What assessment technique is essential if bowel sounds are audible at each auscultation location?
What action will best help the nurse confirm the presence of an S3 heart sound?
What action will best help the nurse confirm the presence of an S3 heart sound?
What assessment should the nurse perform after determining the client has an S3 heart sound?
What assessment should the nurse perform after determining the client has an S3 heart sound?
Which position should the client be placed in to best inspect for jugular vein distention?
Which position should the client be placed in to best inspect for jugular vein distention?
What should the nurse do next after observing a pulsation low and laterally on the neck?
What should the nurse do next after observing a pulsation low and laterally on the neck?
How should the nurse begin the carotid artery assessment?
How should the nurse begin the carotid artery assessment?
How would the nurse interpret the finding of a carotid pulse volume assessed as +2?
How would the nurse interpret the finding of a carotid pulse volume assessed as +2?
What is the significance of not hearing a carotid bruit during assessment?
What is the significance of not hearing a carotid bruit during assessment?
What is the most appropriate action for the nurse if a pulsation is observed but not palpated?
What is the most appropriate action for the nurse if a pulsation is observed but not palpated?
What is the primary purpose of using saline or other prescribed solutions with dressings?
What is the primary purpose of using saline or other prescribed solutions with dressings?
What should be done with excess solution when applying a dressing?
What should be done with excess solution when applying a dressing?
Which step is essential before covering a wound with a dry dressing?
Which step is essential before covering a wound with a dry dressing?
What is the recommended method for layering gauze when using it on a wound?
What is the recommended method for layering gauze when using it on a wound?
What is the correct procedure for applying a secondary dressing over a primary dressing?
What is the correct procedure for applying a secondary dressing over a primary dressing?
When preparing a dressing for application, which action is most critical to achieve effective wound contact?
When preparing a dressing for application, which action is most critical to achieve effective wound contact?
What technique should be avoided when covering a wound with a dressing?
What technique should be avoided when covering a wound with a dressing?
What should be the first consideration when selecting a dressing type for a wound?
What should be the first consideration when selecting a dressing type for a wound?
What should a client with allergies do to minimize exposure to allergens?
What should a client with allergies do to minimize exposure to allergens?
How many Dantrolene capsules should a nurse administer for a prescribed dose of 0.1 grams?
How many Dantrolene capsules should a nurse administer for a prescribed dose of 0.1 grams?
Which observation is expected when using a goniometer to assess a client's joint?
Which observation is expected when using a goniometer to assess a client's joint?
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?
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?
Which best describes the approach a nurse should take when teaching a client about using an inhaler?
Which best describes the approach a nurse should take when teaching a client about using an inhaler?
When should a nurse expect to see improvement in a client’s symptoms after administering an inhaler?
When should a nurse expect to see improvement in a client’s symptoms after administering an inhaler?
What potential effect should a nurse monitor for in a patient taking Dantrolene for spasticity management?
What potential effect should a nurse monitor for in a patient taking Dantrolene for spasticity management?
Which factor should a nurse consider while advising a client with allergies about clothing choices?
Which factor should a nurse consider while advising a client with allergies about clothing choices?
Which of the following foods is not considered a potassium-rich food?
Which of the following foods is not considered a potassium-rich food?
What should the nurse do first when realizing the prescribed dose of hydrochlorothiazide is different from the available tablet strength?
What should the nurse do first when realizing the prescribed dose of hydrochlorothiazide is different from the available tablet strength?
What identifier is least acceptable for the nurse to use when verifying client identity prior to medication administration?
What identifier is least acceptable for the nurse to use when verifying client identity prior to medication administration?
Which of the following is a sign of fluid volume deficit that the nurse must educate the client about?
Which of the following is a sign of fluid volume deficit that the nurse must educate the client about?
What is the highest priority nursing problem for a client recovering from a stroke?
What is the highest priority nursing problem for a client recovering from a stroke?
When taking action to prevent a client from aspirating, what should the nurse do first?
When taking action to prevent a client from aspirating, what should the nurse do first?
What is the most appropriate explanation for the necessity of client identification checks before medication administration?
What is the most appropriate explanation for the necessity of client identification checks before medication administration?
Which symptom is most indicative of fluid volume deficit in an older adult?
Which symptom is most indicative of fluid volume deficit in an older adult?
What is the most appropriate response for a nurse when a client is reluctant to discuss their surgical procedure?
What is the most appropriate response for a nurse when a client is reluctant to discuss their surgical procedure?
How many teaspoons should be administered when metoclopramide is prescribed as 10 mg and the available concentration is 5 mg/5 ml?
How many teaspoons should be administered when metoclopramide is prescribed as 10 mg and the available concentration is 5 mg/5 ml?
Which position is safest for a client receiving a feeding through a gastrostomy tube?
Which position is safest for a client receiving a feeding through a gastrostomy tube?
Which questioning technique is most effective for a nurse to use when gathering information about a client's health problem during an admission interview?
Which questioning technique is most effective for a nurse to use when gathering information about a client's health problem during an admission interview?
What critical information should be considered when positioning an unresponsive client for feeding through a gastrostomy tube?
What critical information should be considered when positioning an unresponsive client for feeding through a gastrostomy tube?
What is a significant risk associated with performing feeds in a supine position?
What is a significant risk associated with performing feeds in a supine position?
What action should a nurse take if a client refuses to discuss their experiences after a mastectomy?
What action should a nurse take if a client refuses to discuss their experiences after a mastectomy?
When calculating medication dosages, what formula should the nurse use?
When calculating medication dosages, what formula should the nurse use?
Which interprofessional team member should the nurse consult to address the client's swallowing difficulties related to dysphagia?
Which interprofessional team member should the nurse consult to address the client's swallowing difficulties related to dysphagia?
What should be the nurse's primary instruction to the UAP when assisting a client with dysphagia during meal times?
What should be the nurse's primary instruction to the UAP when assisting a client with dysphagia during meal times?
Which action should the nurse implement to best support the client's nutritional status given the dysphagia precautions?
Which action should the nurse implement to best support the client's nutritional status given the dysphagia precautions?
What symptom indicates a potential nutritional deficiency that the nurse should investigate further?
What symptom indicates a potential nutritional deficiency that the nurse should investigate further?
What type of diet modification is suggested for a client with dysphagia to ensure safe eating?
What type of diet modification is suggested for a client with dysphagia to ensure safe eating?
If the client exhibits dry and cracked lips, what should the nurse prioritize in the assessment?
If the client exhibits dry and cracked lips, what should the nurse prioritize in the assessment?
What is the nurse's role regarding meals for a client who requires both occupational therapy and dysphagia precautions?
What is the nurse's role regarding meals for a client who requires both occupational therapy and dysphagia precautions?
In which situation would the nurse need to reassess the client's nutrient intake?
In which situation would the nurse need to reassess the client's nutrient intake?
What is the most appropriate pain scale to assess the intensity of the client's pain?
What is the most appropriate pain scale to assess the intensity of the client's pain?
After noting the client's symptoms of dyspnea, dizziness, and chest discomfort, what should be the nurse's immediate assessment action?
After noting the client's symptoms of dyspnea, dizziness, and chest discomfort, what should be the nurse's immediate assessment action?
What is the best approach for the nurse to confirm the client's heart rate after detecting an irregular pulse?
What is the best approach for the nurse to confirm the client's heart rate after detecting an irregular pulse?
To effectively gather subjective data regarding the client's history of chest pain, how should the nurse start?
To effectively gather subjective data regarding the client's history of chest pain, how should the nurse start?
Given the client's report of chest pressure that stops upon resting, what is the most relevant nursing consideration?
Given the client's report of chest pressure that stops upon resting, what is the most relevant nursing consideration?
What nursing action should be taken immediately when the client exhibits an irregular apical rate?
What nursing action should be taken immediately when the client exhibits an irregular apical rate?
Which statement best encompasses the implications of the client's symptoms of tiredness and chest pressure?
Which statement best encompasses the implications of the client's symptoms of tiredness and chest pressure?
What is the primary goal when assessing a client's pain levels in a clinical setting?
What is the primary goal when assessing a client's pain levels in a clinical setting?
What is a common symptom of hypophosphatemia?
What is a common symptom of hypophosphatemia?
Which condition is associated with hypernatremia?
Which condition is associated with hypernatremia?
What is the primary reason for collecting a 24-hour urine sample?
What is the primary reason for collecting a 24-hour urine sample?
How should a face mask be used according to current guidelines?
How should a face mask be used according to current guidelines?
What distinguishes an N95 respirator from a regular face mask?
What distinguishes an N95 respirator from a regular face mask?
Which of the following is a symptom of hyponatremia?
Which of the following is a symptom of hyponatremia?
What instructions should be followed before starting a 24-hour urine collection?
What instructions should be followed before starting a 24-hour urine collection?
Which condition is likely to cause hyperchloremia?
Which condition is likely to cause hyperchloremia?
What should be the primary advice for a client with allergies regarding high pollen count days?
What should be the primary advice for a client with allergies regarding high pollen count days?
How is the dosage of Dantrolene prescribed for a client with spasticity indicated in grams converted for administration?
How is the dosage of Dantrolene prescribed for a client with spasticity indicated in grams converted for administration?
When using a goniometer for measuring a client's knee joint flexion, which measurement should the nurse anticipate?
When using a goniometer for measuring a client's knee joint flexion, which measurement should the nurse anticipate?
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?
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?
What is the most appropriate method for measuring body fat precisely in a clinical setting?
What is the most appropriate method for measuring body fat precisely in a clinical setting?
What device is NOT appropriate for assessing the degree of joint movement during physical assessment?
What device is NOT appropriate for assessing the degree of joint movement during physical assessment?
Which of the following is the best practice for a nurse teaching proper inhaler use?
Which of the following is the best practice for a nurse teaching proper inhaler use?
Which factor can significantly undermine the effectiveness of an inhaler when used by a client?
Which factor can significantly undermine the effectiveness of an inhaler when used by a client?
What is a consequence of using a hydrocolloid dressing for wound care?
What is a consequence of using a hydrocolloid dressing for wound care?
What is the recommended maximum wear time for a hydrocolloid dressing?
What is the recommended maximum wear time for a hydrocolloid dressing?
Which of the following is a primary function of hydrocolloid dressings?
Which of the following is a primary function of hydrocolloid dressings?
What happens if the seal of a hydrocolloid dressing breaks?
What happens if the seal of a hydrocolloid dressing breaks?
In what scenario is it inappropriate to use a hydrocolloid dressing?
In what scenario is it inappropriate to use a hydrocolloid dressing?
How does a hydrocolloid dressing contribute to wound healing?
How does a hydrocolloid dressing contribute to wound healing?
Which characteristic is NOT true about hydrocolloid dressings?
Which characteristic is NOT true about hydrocolloid dressings?
What important aspect should be managed alongside the use of hydrocolloid dressings?
What important aspect should be managed alongside the use of hydrocolloid dressings?
What is the primary nursing action to help a client adapt to the appearance of a stoma?
What is the primary nursing action to help a client adapt to the appearance of a stoma?
Which method is considered the most reliable for confirming the proper placement of a nasogastric tube?
Which method is considered the most reliable for confirming the proper placement of a nasogastric tube?
When addressing a young mother's increase in anxiety, which area should the nurse prioritize obtaining information about first?
When addressing a young mother's increase in anxiety, which area should the nurse prioritize obtaining information about first?
Which advice should the nurse emphasize for a client with multiple allergies?
Which advice should the nurse emphasize for a client with multiple allergies?
What is a common misconception about the presentation of a stoma following surgery?
What is a common misconception about the presentation of a stoma following surgery?
What should the nurse avoid when preparing to teach a client with allergies about managing exposure?
What should the nurse avoid when preparing to teach a client with allergies about managing exposure?
In the context of reducing anxiety during a physical exam, which of these factors should be explored last?
In the context of reducing anxiety during a physical exam, which of these factors should be explored last?
What critical insight should the nurse convey to a client about the changes in stoma size post-surgery?
What critical insight should the nurse convey to a client about the changes in stoma size post-surgery?
What is the most appropriate fluid intake recommendation for a patient with dark amber urine indicating fluid volume deficit?
What is the most appropriate fluid intake recommendation for a patient with dark amber urine indicating fluid volume deficit?
Which vital sign change is most likely when a patient with fluid volume deficit changes position?
Which vital sign change is most likely when a patient with fluid volume deficit changes position?
When assessing for orthostatic vital sign changes, which action should the nurse prioritize first?
When assessing for orthostatic vital sign changes, which action should the nurse prioritize first?
After obtaining the first blood pressure reading, what should the nurse do next?
After obtaining the first blood pressure reading, what should the nurse do next?
Which assessment data is most critical for ongoing evaluation of a patient's fluid volume status?
Which assessment data is most critical for ongoing evaluation of a patient's fluid volume status?
What is the best course of action if a nurse notes inelastic skin turgor during an assessment?
What is the best course of action if a nurse notes inelastic skin turgor during an assessment?
What potential complication is associated with a patient on hydrochlorothiazide who displays signs of fluid volume deficit?
What potential complication is associated with a patient on hydrochlorothiazide who displays signs of fluid volume deficit?
What fluid characteristic most clearly indicates that a patient has a fluid volume deficit?
What fluid characteristic most clearly indicates that a patient has a fluid volume deficit?
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.
###Â 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.
###Â 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.
###Â Assessment of Osteoarthritis
- Goniometer measures the degree of flexion and extension of a joint, which can be used to assess osteoarthritis.
###Â 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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