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Questions and Answers
I should stop taking medication once I feel completely well.
I should stop taking medication once I feel completely well.
False
What should a client do if they have a fever higher than 100° F (37.8° C)?
What should a client do if they have a fever higher than 100° F (37.8° C)?
Which is the first intervention that the nurse implements for a client with a pressure ulcer on the ankle?
Which is the first intervention that the nurse implements for a client with a pressure ulcer on the ankle?
What should the nurse do first when noting decreased tactile sensation in both feet of a client with a 15-year history of diabetes?
What should the nurse do first when noting decreased tactile sensation in both feet of a client with a 15-year history of diabetes?
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Which nursing intervention best assists a bedridden client to keep skin intact?
Which nursing intervention best assists a bedridden client to keep skin intact?
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What is the priority nursing intervention for a patient suspected to be hypothermic?
What is the priority nursing intervention for a patient suspected to be hypothermic?
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Which of the following orders should be questioned for an older adult with decompensated congestive heart failure?
Which of the following orders should be questioned for an older adult with decompensated congestive heart failure?
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What finding indicates hyperthermia during a nursing assessment?
What finding indicates hyperthermia during a nursing assessment?
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Why does the nurse assess the client's pain level after taking routine vital signs?
Why does the nurse assess the client's pain level after taking routine vital signs?
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Which action should the nurse take when observing skin tenting on an older adult client's hand?
Which action should the nurse take when observing skin tenting on an older adult client's hand?
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For which assessment finding should the nurse act immediately after a TURP procedure?
For which assessment finding should the nurse act immediately after a TURP procedure?
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What puts a client at the greatest risk for wound infection?
What puts a client at the greatest risk for wound infection?
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Which clinical manifestations does the nurse expect in a client with early onset of multiple sclerosis (MS)?
Which clinical manifestations does the nurse expect in a client with early onset of multiple sclerosis (MS)?
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A client scores 9 on the Braden Scale. What is the best intervention?
A client scores 9 on the Braden Scale. What is the best intervention?
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Which nursing intervention is most appropriate for a patient experiencing fatigue due to chemotherapy?
Which nursing intervention is most appropriate for a patient experiencing fatigue due to chemotherapy?
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Which intervention should the nurse teach a diabetic client with reduced sensation to prevent injury?
Which intervention should the nurse teach a diabetic client with reduced sensation to prevent injury?
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Which client is at greatest risk for pressure ulcer development?
Which client is at greatest risk for pressure ulcer development?
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What is the appropriate instruction for a nursing assistant to help prevent pressure ulcers in a frail older patient?
What is the appropriate instruction for a nursing assistant to help prevent pressure ulcers in a frail older patient?
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What important information should the nurse include in the teaching about Glucovance?
What important information should the nurse include in the teaching about Glucovance?
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What is the best time to assess a client for problems related to NPH insulin administered at 7 AM?
What is the best time to assess a client for problems related to NPH insulin administered at 7 AM?
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Which intervention should the nurse implement for a client who is immobile due to a recent stroke?
Which intervention should the nurse implement for a client who is immobile due to a recent stroke?
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What position should the client be in to prevent complications due to cranial nerve IX impairment after a stroke?
What position should the client be in to prevent complications due to cranial nerve IX impairment after a stroke?
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Which statement indicates the client needs more teaching about mucositis?
Which statement indicates the client needs more teaching about mucositis?
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What is the highest priority instruction for a young woman being treated with amoxicillin for a urinary tract infection?
What is the highest priority instruction for a young woman being treated with amoxicillin for a urinary tract infection?
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What should the nurse teach to ensure safe medication therapy for a patient after a myocardial infarction?
What should the nurse teach to ensure safe medication therapy for a patient after a myocardial infarction?
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What priority question should the nurse ask during interdisciplinary rounds for a client with an indwelling catheter?
What priority question should the nurse ask during interdisciplinary rounds for a client with an indwelling catheter?
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The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client?
The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client?
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To delay the onset of microvascular and macrovascular complications in a client with newly diagnosed diabetes, which action should the nurse stress?
To delay the onset of microvascular and macrovascular complications in a client with newly diagnosed diabetes, which action should the nurse stress?
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Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? (Select all that apply)
Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? (Select all that apply)
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A client with a pressure ulcer has the following laboratory values. Which action by the nurse is most appropriate?
A client with a pressure ulcer has the following laboratory values. Which action by the nurse is most appropriate?
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When explaining perfusion, which statement by the student nurse indicates understanding?
When explaining perfusion, which statement by the student nurse indicates understanding?
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Which client outcome is indicative of effective hypertension management?
Which client outcome is indicative of effective hypertension management?
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What statement indicates that the client understands teaching about neutropenia?
What statement indicates that the client understands teaching about neutropenia?
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Which action by the nurse takes priority for a client with a nasoenteric feeding tube showing abnormal vital signs?
Which action by the nurse takes priority for a client with a nasoenteric feeding tube showing abnormal vital signs?
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What should the nurse's first action be when a client receiving chemotherapeutic agents intravenously reports burning at the site?
What should the nurse's first action be when a client receiving chemotherapeutic agents intravenously reports burning at the site?
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Which statement indicates best practice for patient safety & quality care regarding tube feeding?
Which statement indicates best practice for patient safety & quality care regarding tube feeding?
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What is the best action for a nurse when a client has a wound with bone exposure?
What is the best action for a nurse when a client has a wound with bone exposure?
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After initial placement of NG tubes is confirmed, how often must placement be checked? (Select all that apply)
After initial placement of NG tubes is confirmed, how often must placement be checked? (Select all that apply)
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What should the priority action of the nurse be if they are unable to withdraw fluid from a Salem sump nasogastric tube before starting the feeding?
What should the priority action of the nurse be if they are unable to withdraw fluid from a Salem sump nasogastric tube before starting the feeding?
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Which assessment is most helpful for a client with a urinary tract infection?
Which assessment is most helpful for a client with a urinary tract infection?
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What statement by the nurse relates to maintaining blood glucose levels no lower than about 74 mg/dl?
What statement by the nurse relates to maintaining blood glucose levels no lower than about 74 mg/dl?
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Which assessment finding could explain the weight gain and hunger of an overweight client?
Which assessment finding could explain the weight gain and hunger of an overweight client?
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What interventions are appropriate for preventing pressure sores for a client who is immobilized? (Select all that apply)
What interventions are appropriate for preventing pressure sores for a client who is immobilized? (Select all that apply)
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What medication should the nurse prepare to administer for a client who experienced symptoms of thrombotic stroke 2 hours ago?
What medication should the nurse prepare to administer for a client who experienced symptoms of thrombotic stroke 2 hours ago?
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What is the priority nursing intervention when administering captopril (Capoten) to a client with hypertension?
What is the priority nursing intervention when administering captopril (Capoten) to a client with hypertension?
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Which adverse effect should the nurse monitor for in a client receiving clopidogrel (Plavix)?
Which adverse effect should the nurse monitor for in a client receiving clopidogrel (Plavix)?
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What is the best response by the nurse when a client receiving chemotherapy asks why protective clothing is worn?
What is the best response by the nurse when a client receiving chemotherapy asks why protective clothing is worn?
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What is the earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation?
What is the earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation?
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Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections?
Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections?
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What interrelated constructs facilitate a nurse to become culturally competent? (Select all that apply)
What interrelated constructs facilitate a nurse to become culturally competent? (Select all that apply)
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The emphasis on understanding cultural influence on health care is important because of:
The emphasis on understanding cultural influence on health care is important because of:
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What is the most important nursing intervention for a patient with severe hypokalemia and a regular heart rhythm?
What is the most important nursing intervention for a patient with severe hypokalemia and a regular heart rhythm?
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Which client is at greatest risk for developing hyponatremia?
Which client is at greatest risk for developing hyponatremia?
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What action must the nurse be prepared to take after accidentally administering 10 mg of morphine intravenously to a client?
What action must the nurse be prepared to take after accidentally administering 10 mg of morphine intravenously to a client?
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Which action does the nurse teach a client to reduce the risk for dehydration?
Which action does the nurse teach a client to reduce the risk for dehydration?
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Which potassium level correlates with confusion in a patient taking furosemide (Lasix)?
Which potassium level correlates with confusion in a patient taking furosemide (Lasix)?
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What is the most reliable means available for assessing core body temperature?
What is the most reliable means available for assessing core body temperature?
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Which intervention will the nurse prepare for a client presenting after prolonged exposure to the cold?
Which intervention will the nurse prepare for a client presenting after prolonged exposure to the cold?
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Which action reflects The Joint Commission's main objective?
Which action reflects The Joint Commission's main objective?
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What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases?
What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases?
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Which client assessment is the most indicative of having pain?
Which client assessment is the most indicative of having pain?
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Which actions are within the scope of nursing practice to improve quality of care?
Which actions are within the scope of nursing practice to improve quality of care?
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Which is most indicative of pain in an older client who is confused? (Select all that apply)
Which is most indicative of pain in an older client who is confused? (Select all that apply)
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The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is:
The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is:
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Which activities most closely match the definition of functional ability?
Which activities most closely match the definition of functional ability?
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Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
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Which medications are unsafe choices for treatment of severe pain in an older adult? (Select all that apply)
Which medications are unsafe choices for treatment of severe pain in an older adult? (Select all that apply)
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Which part of the SBAR hand-off does the nurse's statement about contacting a sitter represent?
Which part of the SBAR hand-off does the nurse's statement about contacting a sitter represent?
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Understanding classifications of pain helps nurses develop a plan of care. What type of pain is characterized by aching and throbbing after tissue injury?
Understanding classifications of pain helps nurses develop a plan of care. What type of pain is characterized by aching and throbbing after tissue injury?
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Which action should the nurse perform FIRST for a client with a high temperature?
Which action should the nurse perform FIRST for a client with a high temperature?
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What is the nurse's first action when checking a client for pain relief after administering morphine and finding the client sleeping with a respiratory rate of 10 breaths/min?
What is the nurse's first action when checking a client for pain relief after administering morphine and finding the client sleeping with a respiratory rate of 10 breaths/min?
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When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that?
When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that?
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Which theory type would the nurse use to develop a plan of care for the best results of a patient's motivation style after a stroke?
Which theory type would the nurse use to develop a plan of care for the best results of a patient's motivation style after a stroke?
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Which clients are at greater risk for hypothermia or frostbite? (Select all that apply)
Which clients are at greater risk for hypothermia or frostbite? (Select all that apply)
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Which statement made by a nurse represents the need for further education regarding pain management in older adult clients?
Which statement made by a nurse represents the need for further education regarding pain management in older adult clients?
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What is the priority action of the nurse when a spectator comes in with a temperature of 104.1 F and shows signs of heat stroke?
What is the priority action of the nurse when a spectator comes in with a temperature of 104.1 F and shows signs of heat stroke?
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What intervention does the nurse perform first when a client receiving potassium chloride intravenously reports burning around the IV site?
What intervention does the nurse perform first when a client receiving potassium chloride intravenously reports burning around the IV site?
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Which economic situation presents the most serious problem for an older adult client who lives alone?
Which economic situation presents the most serious problem for an older adult client who lives alone?
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Unrelieved pain has been associated with?
Unrelieved pain has been associated with?
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Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion?
Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion?
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Which client is at greatest risk for dehydration?
Which client is at greatest risk for dehydration?
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Which client does the nurse assess most carefully for hyperkalemia?
Which client does the nurse assess most carefully for hyperkalemia?
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Which age-related change may have contributed to digoxin toxicity for an older adult client?
Which age-related change may have contributed to digoxin toxicity for an older adult client?
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Which statement made by the client indicates understanding of dehydration after being treated?
Which statement made by the client indicates understanding of dehydration after being treated?
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Which intervention is the priority when a nurse notes diminished handgrip strength in a client with hypokalemia?
Which intervention is the priority when a nurse notes diminished handgrip strength in a client with hypokalemia?
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How many tablets of Lasix (furosemide) 40 mg should be given to achieve a prescribed dosage of 60 mg?
How many tablets of Lasix (furosemide) 40 mg should be given to achieve a prescribed dosage of 60 mg?
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Which food selection by a client indicates understanding of dietary sodium restrictions?
Which food selection by a client indicates understanding of dietary sodium restrictions?
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Which behavior best indicates that a client is experiencing changes associated with acute pain?
Which behavior best indicates that a client is experiencing changes associated with acute pain?
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Which finding in an older client should the nurse assess first to prevent overhydration?
Which finding in an older client should the nurse assess first to prevent overhydration?
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Which tasks can the nurse delegate to unlicensed assistive personnel for a client who had a stroke?
Which tasks can the nurse delegate to unlicensed assistive personnel for a client who had a stroke?
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When addressing patient education quality concerns, which interrelated concept is most relevant for a nurse manager?
When addressing patient education quality concerns, which interrelated concept is most relevant for a nurse manager?
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Which of the following is not a risk factor for impaired thermoregulation?
Which of the following is not a risk factor for impaired thermoregulation?
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What is the priority intervention for a client in physical restraints?
What is the priority intervention for a client in physical restraints?
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Which client is most likely not to be treated adequately for pain?
Which client is most likely not to be treated adequately for pain?
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Based on observing a client listening to music before surgery, which nonpharmacologic intervention for pain relief might the nurse try?
Based on observing a client listening to music before surgery, which nonpharmacologic intervention for pain relief might the nurse try?
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Study Notes
Patient Education Approaches
- Informal teaching involves one-on-one interactions, addressing individual patient needs.
- Formal education uses standardized content and group-focused plans.
Motivation Theories in Care Planning
- Cognitive theory emphasizes ARCS (Attention, Relevance, Confidence, Satisfaction) to motivate learning.
- Field theory focuses on personal achievement and power as motivators, while sociologic theories do not focus on motivation.
Risk Factors for Hypothermia/Frostbite
- Increased risk in older adults, those with poor nutrition, alcohol users, smokers, and individuals with chronic illnesses.
Pain Management in Older Adults
- Older adults may under-report pain; they experience pain similarly to younger adults.
- Treatment of pain is critical for promoting overall wellness.
Emergency Response for Heat Stroke
- Priority action includes cooling the patient; intravenous fluids and medications may be less effective in urgent situations.
IV Administration of Potassium Chloride
- Potassium chloride is a strong tissue irritant; immediate action is to stop the infusion if patient experiences burning.
Economic Concerns for Older Adults
- Social Security may be the primary source of income, making it difficult to manage increased living costs.
Effects of Unrelieved Pain
- Uncontrolled pain is linked to prolonged stress responses and systemic harm, affecting overall health and recovery.
Handling Dehydration-Induced Confusion
- Rapidly increasing IV fluid rates can improve cerebral perfusion and relieve confusion caused by dehydration.
Dehydration Risk in Specific Populations
- Older adults, especially those with cognitive impairments, are at a heightened risk for dehydration.
Monitoring for Hyperkalemia
- Individuals using potassium-based salt substitutes are at increased risk; education on label reading is essential.
Digoxin Toxicity in Older Adults
- Decreased renal blood flow and glomerular filtration in aging increase the risk of accumulation and toxicity from medications like digoxin.
Understanding of Dehydration
- Monitoring daily weight provides insight into fluid status and hydration levels, with significant weight loss indicating dehydration.
Priority Interventions for Hypokalemia
- Respiratory assessments take precedence due to the risk of respiratory failure linked with low potassium levels.
Calculating Medication Dosage
- Dosage calculations require understanding of desired and available medication strengths.
Dietary Sodium Restriction
- Choosing whole foods like fresh produce and avoiding processed foods indicates understanding of dietary sodium restrictions.
Behavioral Indicators of Acute Pain
- The inability to concentrate is a key behavioral sign of acute pain, while chronic pain more often involves emotional withdrawal.
Risk Assessment for Overhydration
- Clients receiving blood products, such as packed red blood cells, require careful monitoring for overhydration.
Delegation of Tasks in Nursing
- Unlicensed assistive personnel can assist with client meals, but not with assessments or care plans.
Quality of Patient Education
- Nurse managers need to consider technology along with health promotion and patient attributes in education quality.
Thermoregulation Risk Factors
- Factors like cognitive impairment and environmental exposure increase vulnerability to thermoregulation issues, unlike physical agility.
Monitoring Clients in Restraints
- Frequent assessment and timely release of restraints are vital to prevent injury and monitor client well-being.
Pain in Chronic Conditions
- Assessing the cause of elevated vital signs in clients with chronic pain is crucial for appropriate management.
Inequitable Pain Treatment
- Nonverbal clients, such as those with expressive aphasia, are at greater risk for inadequate pain management.
Nonpharmacologic Pain Relief Strategies
- Imagery as a distraction technique can be beneficial for pain management, especially in the postoperative setting.
Cultural Competence in Nursing
- Key constructs for culturally competent nursing include cultural desire, self-awareness, cultural knowledge, and skill.
Importance of Cultural Understanding in Healthcare
- Increasing global diversity necessitates understanding cultural influences on health care to provide effective patient care.### Nursing Assessment and Interventions
- Regular heart rhythm indicates monitoring for conditions like hypokalemia, which can cause postural hypotension and muscle weakness.
- Essential to institute fall precautions for patients with hypokalemia due to risks of falls from muscle weakness.
Fluid and Electrolyte Imbalances
- Clients who are NPO and receiving intravenous D5W are at high risk for hyponatremia; D5W lacks electrolytes.
- Monitoring potassium levels is crucial; hypokalemia can lead to confusion and lethargy, with the dangerous level being below 3.5 mEq/L.
Pain Management and Medication Safety
- Administering excessive morphine can cause respiratory depression; naloxone (Narcan) can reverse overdose effects.
- Certain medications (meperidine, propoxyphene, codeine) are unsafe for older adults due to the risk of accumulation of toxic metabolites; morphine is generally safe with monitoring.
Core Temperature Measurement
- Rectal thermometers provide the most reliable assessment of core body temperature, essential for accurate readings in cases of suspected thermoregulation issues.
Hypothermia Management
- In mild hypothermia, immediate intervention includes providing dry clothing and warm blankets.
- Continuous monitoring of vital signs and appropriate rewarming techniques is necessary for severe cases.
Safety and Quality of Care
- Prioritize patient safety by assessing respiratory status, especially when administering opioids.
- Utilize the Rapid Response Team (RRT) for significant changes in patient conditions, like a drastic drop in blood pressure.
Functional Ability and Family Assessments
- Functional ability includes the capacity to perform daily living activities, not just physical independence.
- Family assessments inform about family structure and dynamics but do not emphasize political views.
Observation of Pain in Older Adults
- Nonverbal cues such as facial grimace, crying, and restlessness are key indicators of pain in cognitively impaired older adults.
Managing High Temperatures and Hyperthermia
- Provide cool packs directly to the skin's surface in febrile patients to manage high temperatures effectively, avoiding fans that may spread pathogens.
Collaborative Care in Hypertension
- Initial teaching goals for new hypertensive patients focus on understanding the importance of medication adherence for management.
Skin Assessment in Older Adults
- Assess skin turgor on areas like the forehead and abdomen instead of hands, which may not reflect turgor accurately due to age-related changes.### Assessment Findings After TURP
- Continuous urge to void with catheter present is expected.
- Passing small blood clots post-catheter removal is normal.
- Bright red drainage with multiple blood clots signals arterial bleeding, requiring immediate action.
Risk for Wound Infection
- Immune compromised status presents the greatest risk for infection.
- Coexisting conditions and deep wounds also increase susceptibility but are secondary.
Early Onset Multiple Sclerosis Symptoms
- Early signs include nystagmus and diplopia (eye movement issues).
- Hyperresponsive reflexes, excessive somnolence, and heat intolerance occur later.
Braden Scale Score of 9 Intervention
- A score of 11 or lower indicates severe risk for pressure ulcers.
- Consulting with the healthcare provider is necessary for enhanced skin protection.
Managing Fatigue in Chemotherapy Patients
- Prioritizing nursing care throughout the day is crucial to manage fatigue.
- Activities should be paced to conserve energy, while adequate sleep alone won’t resolve fatigue.
Injury Prevention for Diabetic Clients
- Using a bath thermometer is essential for testing water temperature due to numbness.
- Daily foot examinations are vital, but do not directly prevent injuries.
Greatest Pressure Ulcer Development Risk
- An incontinent client with limited mobility is at the highest risk due to dual risk factors.
Preventing Pressure Ulcers in Older Patients
- Turning the patient at least every 2 hours is crucial to avoid skin damage.
Education on Glucovance for Diabetic Patients
- Glucovance is a combination of glyburide and metformin to simplify treatment.
Assessment Timing for NPH Insulin
- Assess for complications related to NPH insulin at 4 PM, when peak effects are expected.
Interventions for Immobility Post-Stroke
- Applying sequential compression stockings is key to preventing complications like DVT.
Nutritional Interventions for Stroke Patients
- Positioning the client in high Fowler's position aids in swallowing and reduces aspiration risk.
Patient Education on Mucositis
- Avoid alcohol-based mouth rinses, as they exacerbate irritation.
Antibiotic Use in Women with Urinary Tract Infections
- Counsel clients to use a second form of birth control while taking amoxicillin, as it may reduce contraceptive effectiveness.
Combination Drug Therapy for Hypertension
- Include aspirin, aldosterone antagonists, ACE inhibitors/ARBs, beta blockers, and diuretics in teaching plans for managing hypertension.
Orienting Clients with Disorientation
- Family photographs can help reorient confused patients post-stroke.
Indications of Improved Nutritional Status
- An increase in prealbumin levels is a reliable indicator of enhanced nutritional status.
Important Factors in Health History for Elimination
- Recent changes in elimination patterns, color/consistency of stool or urine, and discomfort during elimination are all critical.
Managing Indwelling Catheter Risk
- Prioritize discussions about the necessity of indwelling catheters to reduce the risk of infections.
Neurologic Deficits in Right Cerebral Hemisphere Stroke
- Look for impaired proprioception due to stroke effects on spatial awareness.
Diabetes Management Goals
- Control hyperglycemia effectively to prevent long-term complications in diabetes.
Enteral Tube Feeding Safety Interventions
- Monitor residual volume every 4-6 hours, utilize clean technique when changing feeding systems, and maintain the head of the bed at 30 degrees.
Client's Nutritional Status and Wound Healing
- Request dietary consult when prealbumin levels are low, indicating nutritional risk affecting wound healing.
Monitoring Perfusion
- Evaluate perfusion through vital signs and capillary refill to assess adequacy for vital organs.
Effective Hypertension Management Indicators
- Absence of renal impairment signifies successful hypertension management.
Neutropenia Client Education
- Instruct clients to report any increase in temperature promptly for risk management.
Aspiration Risk in Nasoenteric Feeding Tube Clients
- Prioritize assessing lung sounds and oxygen saturation for clients showing respiratory distress after feeding.
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Description
This quiz focuses on patient education approaches in Medical Surgical Nursing, specifically emphasizing informal teaching methods. It is designed to enhance understanding of individualized nursing education strategies. Perfect for HESI test preparation and nursing students.
