Podcast
Questions and Answers
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?
During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?
During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
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A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.)
A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.)
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A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?
A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?
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A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure?
A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure?
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A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client’s dentures be removed prior to surgery. Which of the following responses should the nurse provide?
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client’s dentures be removed prior to surgery. Which of the following responses should the nurse provide?
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A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
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A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client’s wound has eviscerated?
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client’s wound has eviscerated?
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A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
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A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
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A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?
A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?
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A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
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A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
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A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
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A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?
A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?
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A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?
A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?
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A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
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A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?
A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?
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A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?
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A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include?
A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include?
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A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?
A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?
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A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
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A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?
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A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?
A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?
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A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
Fill in the blank
A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)
Fill in the blank
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A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?
A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?
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A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
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A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?
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A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?
A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?
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A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?
A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?
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A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?
A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?
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A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?
A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?
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A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
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A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?
A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?
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A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?
A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?
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A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?
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A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select?
A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select?
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A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?
A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?
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A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients’ commitment to a long-term goal of weight loss?
A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients’ commitment to a long-term goal of weight loss?
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A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
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A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?
A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?
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A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?
A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?
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A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
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A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?
A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?
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A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
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A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
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A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?
A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?
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Study Notes
Gastric Decompression
- A single-lumen nasogastric (NG) tube is inserted to remove gastric contents and relieve pressure in the stomach
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Actions for plan of care:
- Monitor NG tube placement regularly
- Assess and maintain patency of the tube
- Check for aspiration by observing for signs of respiratory distress
- Irrigate the tube with saline solution as ordered
- Monitor the amount and character of gastric drainage
- Monitor client's vital signs frequently
- Maintain meticulous oral hygiene
- Monitor for complications such as aspiration, tube displacement, and infection
Anorexia and Nausea
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Interventions for anorexia and nausea related to cancer treatment:
- Assess nutritional status using tools such as anthropometrics and dietary intake history
- Provide small, frequent snacks
- Offer bland and non-irritating foods
- Encourage adequate hydration
- Administer antiemetics as ordered
- Provide oral care to prevent mucositis
- Facilitate a comfortable eating environment free of distractions
- Educate the client about strategies to minimize nausea such as relaxation techniques, aromatherapy, or ginger
Data Security
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Acceptable environments for discussing client information:
- Private meeting rooms
- Designated workstations
- Client rooms when the client is present
- Telephone conferences with authorized personnel
- Electronic health records with password-protected access
Nurse-Client Termination
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Concepts for discussion during termination:
- Review the client's progress and accomplishments
- Identify future goals and resources
- Explore any feelings related to the ending of the relationship
- Reinforce the client's strengths and coping mechanisms
- Establish a plan for ongoing support and referrals
- Summarize significant aspects of the therapeutic relationship, including any challenges or highlights
- Express gratitude for the opportunity to help the client
NG Tube Insertion
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Actions to facilitate NG tube insertion:
- Explain the procedure to the client
- Position the client in a high Fowler's position
- Provide comfort and reassurance
- Use a water-soluble lubricant on the tube
- Advance the tube slowly while assessing for resistance
- Use a stethoscope to assess for placement
- Obtain an x-ray to confirm placement
Supination
- Supination of the hand is when the palm faces upward
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Examples of supination in hand exercises:
- Turning the palm up while keeping the forearm straight
- Pouring water from a cup into a glass
- Holding a book in an upright position
Vaginal Medication
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Actions to take when administering vaginal medication:
- Maintain privacy and dignity for the client
- Assist the client to a dorsal recumbent position with their knees flexed and feet flat on the bed
- Lubricate the suppository or applicator
- Gently insert the suppository along the posterior vaginal wall
- Instruct the client to remain lying down for 15-20 minutes
- Provide education and reassurance
- Document administration of the medication and the client's response
Denture Removal
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Response if an older adult client becomes agitated about denture removal:
- Explain the reason why dentures need to be removed
- Reassure the client that their dentures will be safely stored and returned
- Offer alternative methods to secure the dentures, such as a denture cup
- Provide emotional support and understanding to the client
CPR
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First response in CPR:
- Assess for responsiveness by calling out to the client and gently shaking their shoulders
- Call for help if the client does not respond
- Check for a pulse by placing two fingers on the carotid artery
Eviscerated Wound
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First action after discovering an eviscerated wound:
- Call for help immediately
- Stay with the client and provide reassurance
- Cover the wound with sterile saline-soaked gauze
- Keep the client supine with elevated legs
- Monitor vital signs and observe for signs of shock
Chest Physiotherapy
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Actions for chest physiotherapy:
- Assess lung sounds before and after treatment
- Explain the procedure to the client
- Position the client in an upright position
- Use percussion, vibration, and postural drainage techniques
- Encourage coughing and deep breathing after treatment
- Monitor for effectiveness and document responses
- Provide comfort and reassurance during the procedure
- Maintain client safety by using proper positioning and techniques
Stool Specimen
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Actions for collecting a stool specimen:
- Obtain a clean, sterile specimen container
- Instruct the client to collect the stool in the container
- Avoid collecting urine or toilet paper in the container
- Label the container with the client's name, date, and time of collection
- Transport the container to the laboratory for analysis
Terminal Stage Lung Cancer
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Outcomes facilitated by terminal stage lung cancer care:
- Maintain comfort and manage symptoms
- Preserve dignity and respect for the client
- Provide emotional support to the client and their family
- Facilitate a peaceful end-of-life experience
Blood Spill on Gloves
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Actions after blood spill on gloved hands:
- Immediately remove contaminated gloves
- Wash hands thoroughly with soap and water
- Dispose of contaminated gloves appropriately
- Report the incident to the appropriate personnel
- Assess for potential exposure risks for the nurse and client
Intake and Output
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Total output calculations:
- Urine: 350 mL + 200 mL + 150 mL = 700 mL
- Wound drainage: 2 tsp * 5 mL/tsp = 10 mL
- Emesis: 2 oz * 30 mL/oz = 60 mL
- Total output: 700 mL + 10 mL + 60 mL = 770 mL
Wound Healing
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Observations to report about wound healing:
- Signs of infection, such as redness, swelling, warmth, pain, or purulent drainage
- Wound dehiscence, separation of wound edges
- Wound evisceration, protrusion of internal organs through the wound
- Excessive bleeding or drainage from the wound
- Delayed wound healing or failure to progress
Timolol Eye Drops
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Action after observing incorrect administration of eye drops:
- Provide appropriate teaching and demonstration for the client
- Clarify any misunderstandings about the procedure
- Reinforce the importance of proper technique to prevent medication errors and ensure effectiveness
- Monitor the client's ability to administer the medication correctly
Cancer Diagnosis
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Responding to a client's statement after cancer diagnosis:
- Acknowledge the client's feelings and validate their concerns
- Offer support and encouragement to the client
- Openly discuss the client's concerns and provide resources
- Encourage the client to develop coping mechanisms to manage stress and difficult emotions
- Facilitate a safe space for the client to express their fears, anxieties, and hopes
Cleansing Enema
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Actions to take when administering a cleansing enema:
- Warm the enema solution to body temperature
- Assist the client into a left Sims position
- Lubricate the rectal tube with a water-soluble lubricant
- Gently insert the rectal tube into the rectum
- Administer the enema solution slowly
- Instruct the client to retain the solution for 5-10 minutes
- Assist the client with toileting after the enema
Iatrogenic HAI
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Iatrogenic health care-associated infections (HAIs):
- Healthcare workers are the source of infection
- Caused by medical procedures or interventions
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Examples include:
- Catheter-associated urinary tract infections (UTIs)
- Central line-associated bloodstream infections (CLABSI)
- Ventilator-associated pneumonia (VAP)
Immobility
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Health alterations caused by immobility:
- Muscle atrophy and weakness
- Contractures
- Osteoporosis
- Deep vein thrombosis (DVT)
- Pneumonia
- Constipation
- Pressure ulcers
- Skin breakdown
- Depression
Nutritious Diets
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Statement about nutritious diets for women:
- Include a variety of fruits, vegetables, whole grains, and lean protein sources
- Limit processed foods, sugary drinks, unhealthy fats, and excessive sodium
- Consider individual nutritional needs based on age, activity level, and health conditions
- Promote mindful eating habits to improve overall health and well-being
Surgical Suite Table
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Phase of care where the client is transferred to the surgical suite table:
- Intraoperative phase
IV Infusion Rate
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IV infusion rate calculation:
- Volume (mL) x drop factor (gtt/mL) / time (min)
- 700 mL x 60 gtt/mL / (24 hr x 60 min/hr)
- = 43.75 gtt/min
- Rounded to the nearest whole number: 44 gtt/min
Client Refusing Ambulation
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Actions for a client refusing ambulation:
- Assess the client's pain level and identify potential contributing factors
- Encourage the client to participate in a plan to address the pain
- Provide comfort measures such as medication, heat, or massage
- Offer alternative movement strategies such as passive range-of-motion exercises
- Collaborate with the interdisciplinary team to address any underlying concerns
- Maintain a positive and supportive approach to encourage the client to participate in their care
Complete Protein
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Foods that are sources of complete protein:
- Dairy products (e.g., milk, yogurt, cheese)
- Meat (e.g., beef, chicken, fish)
- Eggs
- Soy products (e.g., tofu, tempeh)
Liquid Medication
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Teaspoons in 10 mL of liquid medication:
- 1 teaspoon = 5 mL
- 10 mL / 5 mL/teaspoon = 2 teaspoons
Asthma and Food Allergies
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First action when performing an admission assessment for a client with asthma and food allergies:
- Assess the client's current medical history including details of asthma, food allergies, and any previous allergic reactions.
Postoperative Gas Pains
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Postoperative gas pains:
- Normal complication following abdominal surgery
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Caused by:
- Air trapped in the bowel due to manipulation during surgery
- Inflammation of the bowel
- Constipation
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Interventions:
- Encourage ambulation
- Provide pain medication
- Apply moist heat to the abdomen
- Promote bowel function with diet and laxatives
- Monitor for bowel sounds and distention
Client Refusing Visitors
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Comment for a client refusing visitors:
- "I understand how you're feeling, and I'll respect your wishes."
Xerostomia
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Nutrient affected by lack of salivary amylase:
- Carbohydrates
- Salivary amylase breaks down starches in the mouth, aiding in digestion.
Dressing Change
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Actions for a dressing change:
- Gather necessary supplies: clean gloves, sterile gauze pads, tape, sterile saline solution, and a waste container
- Explain the procedure to the client
- Wash hands thoroughly
- Don clean gloves and assess the wound
- Remove the old dressing carefully
- Clean the wound with sterile saline solution
- Apply a new sterile dressing and secure it with tape
- Document the dressing change and the client's response
Enteral Feedings and Urine Specific Gravity
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Action for high urine specific gravity during enteral feedings:
- Encourage fluid intake to prevent dehydration
Side Rails
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Statement indicating further teaching about side rails:
- "Side rails are only used to prevent falls."
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Side rails are used for a variety of reasons, including:
- Prevent falls
- Provide stability for clients
- Assist with client movement
- Prevent dislodgement of medical devices
Passive Range of Motion
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Actions for passive range of motion exercises:
- Support the joint being moved
- Move the joint through its full range of motion
- Perform slow, gentle movements
- Avoid forcing the joint beyond its normal range
- Assess for pain or resistance during the movements
Incomplete Protein
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Incomplete protein food:
- Beans
Confusion
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Laboratory value that can cause confusion:
- Sodium (hyponatremia or hypernatremia)
Postoperative Wound Healing
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Actions to promote wound healing:
- Ensure adequate nutrition with a high-protein diet
- Maintain adequate hydration
- Monitor wound status and signs of infection
- Encourage mobility to stimulate circulation
- Administer medications as prescribed
- Provide wound care according to provider orders
- Educate the client about wound care and prevention of infection
- Consult with a dietitian to obtain a nutritional plan to support wound healing
Peripheral IV Insertion
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Site selection for peripheral IV insertion:
- Choose a vein that is visible, palpable, and free of inflammation or infection
- Consider the client's age, activity level, and medical history
- Use the most distal site possible to preserve access to other veins
- Use a site that is easily accessible for monitoring and maintenance of the IV
Total Calcium
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Findings expected with a high total calcium level (12.7 mg/dL):
- Constipation
- Anorexia
- Polyuria
- Fatigue
- Mental changes
- Muscle weakness
- Kidney stones
Weight Loss Strategies
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Actions to improve commitment to weight loss:
- Set realistic and achievable goals
- Develop a personalized weight loss plan
- Encourage group support through weight-loss groups or online forums
- Provide education on healthy eating habits, exercise, and behavior modification techniques
- Monitor progress regularly and celebrate successes
- Address any barriers to weight loss and provide strategies for overcoming them
- Foster a positive and supportive environment to encourage the client's commitment and persistence
Unresponsive Client
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First action for an unresponsive client:
- Start CPR immediately
Cane Walking
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Client action indicating understanding of cane walking:
- The client holds the cane on the opposite side of their affected leg and moves the cane forward with each step.
Crutch Usage
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Client action indicating safe crutch usage:
- The client keeps the crutch tips 6 inches to the side of the feet and 12 inches in front of the feet.
Hearing Impairment
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Intervention for speaking to a client with a hearing impairment:
- Sit facing the client, ensuring that the client can see the nurse's face and lips.
Home Health Services
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Client statement indicating understanding of home health services:
- "My nurse will come to my home every day to change my dressing."
Hand Hygiene
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Statement indicating understanding of proper hand hygiene:
- "I should wash my hands for 20 seconds before and after caring for a client."
NG Tube Insertion for Bowel Obstruction
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First action when inserting an NG tube for bowel obstruction:
- Check for contraindications, such as recent nose or facial surgery, esophageal stricture, or gastric perforation.
Neurological Assessment
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Cranial nerve tested by sticking out the tongue:
- Hypoglossal nerve (XII)
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Description
This quiz focuses on the essential nursing interventions for managing a patient with a single-lumen nasogastric (NG) tube. It covers various actions the nurse should implement to ensure proper gastric decompression and client safety. Select all applicable actions to demonstrate your understanding of NG tube care.
