Podcast
Questions and Answers
How often should passive range-of-motion exercises to the lower extremities be performed?
How often should passive range-of-motion exercises to the lower extremities be performed?
Two to three times each day
What should the nurse place at the end of the client's bed to protect the heels?
What should the nurse place at the end of the client's bed to protect the heels?
Footboard or foot boots
What type of pressure injury is noted on the client's left heel?
What type of pressure injury is noted on the client's left heel?
Stage 1 pressure injury
Which actions should the nurse take when assessing a client with a peripheral IV? (Select all that apply)
Which actions should the nurse take when assessing a client with a peripheral IV? (Select all that apply)
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Which interventions should be included for a client on isolation precautions for tuberculosis? (Select all that apply)
Which interventions should be included for a client on isolation precautions for tuberculosis? (Select all that apply)
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The client is at risk for _____ as evidenced by the client's _____.
The client is at risk for _____ as evidenced by the client's _____.
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What indicates improvement in a client's condition in a medical-surgical unit?
What indicates improvement in a client's condition in a medical-surgical unit?
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The first client the nurse should assess is _____ followed by _____.
The first client the nurse should assess is _____ followed by _____.
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Which findings require follow-up for a client with COPD? (Select 3)
Which findings require follow-up for a client with COPD? (Select 3)
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Which actions should the nurse take for a client with abdominal pain? (Select all that apply)
Which actions should the nurse take for a client with abdominal pain? (Select all that apply)
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What statement about advance directives should the nurse make?
What statement about advance directives should the nurse make?
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What is the correct order of steps for administering insulin?
What is the correct order of steps for administering insulin?
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Which technique should the nurse use to perform a Romberg test?
Which technique should the nurse use to perform a Romberg test?
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Which instructions should the nurse provide for the use of a home oxygen concentrator?
Which instructions should the nurse provide for the use of a home oxygen concentrator?
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Which food should be included in the diet of a client at risk for hypokalemia?
Which food should be included in the diet of a client at risk for hypokalemia?
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What action should the nurse take to ensure otic medication reaches the inner ear?
What action should the nurse take to ensure otic medication reaches the inner ear?
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What should the nurse do when administering an opioid medication and drawing out 1 mL from a 2 mL vial?
What should the nurse do when administering an opioid medication and drawing out 1 mL from a 2 mL vial?
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When monitoring a client receiving IV fluids for adverse effects, which assessment is the priority?
When monitoring a client receiving IV fluids for adverse effects, which assessment is the priority?
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What action should the nurse take for a client expressing anger about their diagnosis of colorectal cancer?
What action should the nurse take for a client expressing anger about their diagnosis of colorectal cancer?
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Which type of activity should the nurse recommend to an older adult at risk for osteoporosis?
Which type of activity should the nurse recommend to an older adult at risk for osteoporosis?
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When descending stairs, the client should first shift their weight to their left leg.
When descending stairs, the client should first shift their weight to their left leg.
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How far should the client place their crutches in front of each foot?
How far should the client place their crutches in front of each foot?
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The client should hold both crutches by their hand bars in one hand just before sitting down.
The client should hold both crutches by their hand bars in one hand just before sitting down.
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How should the shoulder rests of the crutches be adjusted?
How should the shoulder rests of the crutches be adjusted?
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Which method should the nurse use as a psychomotor approach to learning for a group of adolescents with a surgical ostomy?
Which method should the nurse use as a psychomotor approach to learning for a group of adolescents with a surgical ostomy?
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Which intervention should the nurse implement to prevent infection before IV catheter insertion?
Which intervention should the nurse implement to prevent infection before IV catheter insertion?
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Which instruction should the nurse provide for tracheostomy care at home?
Which instruction should the nurse provide for tracheostomy care at home?
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Which statement indicates that the client with terminal liver cancer is experiencing spiritual distress?
Which statement indicates that the client with terminal liver cancer is experiencing spiritual distress?
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Which finding during a skin assessment might indicate skin malignancy?
Which finding during a skin assessment might indicate skin malignancy?
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What is the first action the nurse should take when teaching a client about insulin self-administration?
What is the first action the nurse should take when teaching a client about insulin self-administration?
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Which intervention should a nurse take to minimize injury risk for a client with dementia?
Which intervention should a nurse take to minimize injury risk for a client with dementia?
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The client should hold the cane on the weaker side of their body.
The client should hold the cane on the weaker side of their body.
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What size suction catheter should the nurse select for suctioning a client with a tracheostomy?
What size suction catheter should the nurse select for suctioning a client with a tracheostomy?
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What should the nurse do first when finding a client on the bathroom floor?
What should the nurse do first when finding a client on the bathroom floor?
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What is the recommended screening for clients at average risk for colon cancer starting at age 45?
What is the recommended screening for clients at average risk for colon cancer starting at age 45?
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The nurse should place the client in a prone position to apply sequential compression sleeves.
The nurse should place the client in a prone position to apply sequential compression sleeves.
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What would be the nurse's appropriate response to a client asking about resuscitation?
What would be the nurse's appropriate response to a client asking about resuscitation?
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Which strategy should the nurse implement for effective time management?
Which strategy should the nurse implement for effective time management?
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Which statement indicates the client's understanding of protective isolation precautions?
Which statement indicates the client's understanding of protective isolation precautions?
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Which assessments should the nurse use to identify the client's safety needs?
Which assessments should the nurse use to identify the client's safety needs?
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For which finding should the nurse intervene for a client who has been immobile for 3 weeks?
For which finding should the nurse intervene for a client who has been immobile for 3 weeks?
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Which action should the nurse take to prevent the spread of infection?
Which action should the nurse take to prevent the spread of infection?
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After securing a safe environment, what is the next action the nurse should take for a client who can bear weight on one leg?
After securing a safe environment, what is the next action the nurse should take for a client who can bear weight on one leg?
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Which item should the nurse document as 120 mL of fluid?
Which item should the nurse document as 120 mL of fluid?
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Which component of the medication prescription should the nurse verify with the provider?
Which component of the medication prescription should the nurse verify with the provider?
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Which therapy is contraindicated for a client with herpes zoster?
Which therapy is contraindicated for a client with herpes zoster?
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Which client statement describes the quality of pain during a pain assessment?
Which client statement describes the quality of pain during a pain assessment?
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What is the appropriate response by the nurse to a client demonstrating anger?
What is the appropriate response by the nurse to a client demonstrating anger?
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In which situation does the nurse demonstrate the ethical principle of veracity?
In which situation does the nurse demonstrate the ethical principle of veracity?
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Which action by a newly licensed nurse during a sterile field preparation requires intervention?
Which action by a newly licensed nurse during a sterile field preparation requires intervention?
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The client has manifestations of _____ as evidenced by the client's ______.
The client has manifestations of _____ as evidenced by the client's ______.
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Which finding requires intervention by the nurse for a client with paraplegia?
Which finding requires intervention by the nurse for a client with paraplegia?
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Which action should a nurse take to decrease a client's risk of developing plantar flexion contractures?
Which action should a nurse take to decrease a client's risk of developing plantar flexion contractures?
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What is the nurse's priority action for a postoperative client refusing to use an incentive spirometer?
What is the nurse's priority action for a postoperative client refusing to use an incentive spirometer?
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Which instruction should a nurse give for self-administering heparin?
Which instruction should a nurse give for self-administering heparin?
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What piece of information is the priority for a nurse to provide in a change-of-shift report for a pneumonia client?
What piece of information is the priority for a nurse to provide in a change-of-shift report for a pneumonia client?
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Which action should a nurse take when inserting an NG tube?
Which action should a nurse take when inserting an NG tube?
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Which statement indicates a client understands the use of a behind-the-ear hearing aid?
Which statement indicates a client understands the use of a behind-the-ear hearing aid?
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Which statement indicates effective teaching about using a walker?
Which statement indicates effective teaching about using a walker?
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What technique should a nurse use when performing nasotracheal suctioning?
What technique should a nurse use when performing nasotracheal suctioning?
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What is the correct flow rate for oxygen via nasal cannula?
What is the correct flow rate for oxygen via nasal cannula?
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At what rate should a nurse set the infusion pump for a heparin infusion prescribed at 800 units/hr?
At what rate should a nurse set the infusion pump for a heparin infusion prescribed at 800 units/hr?
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Which findings at the IV site indicate infiltration?
Which findings at the IV site indicate infiltration?
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What could indicate potential elder abuse during a home health nurse's assessment?
What could indicate potential elder abuse during a home health nurse's assessment?
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Which action should a nurse take when planning to insert a peripheral IV catheter for an older adult?
Which action should a nurse take when planning to insert a peripheral IV catheter for an older adult?
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Which action should the nurse take when performing wound irrigation?
Which action should the nurse take when performing wound irrigation?
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Study Notes
Client Assessment Prioritization
- Client with postoperative pain rated 8/10 is a priority for assessment due to potential respiratory distress.
- Client diagnosed with heart failure is the second priority due to low potassium level, increasing risk of dysrhythmias.
- Other clients, although requiring attention, have conditions that are less immediate.
COPD Care Follow-Up
- Crackles in breath sounds indicate pneumonia and need follow-up.
- Oxygen saturation below 95% indicates hypoxia, requiring nursing intervention.
- An elevated temperature suggests infection and necessitates further evaluation.
- Blood pressure and heart rate within normal range do not require follow-up.
Emergency Department Client Care
- Positioning client on left side with right knee flexed aids in enema administration.
- Cleansing enema is prescribed to facilitate bowel elimination, especially if imaging indicates obstruction.
- Auscultation of bowel sounds is critical to assess gastrointestinal function.
- Chest X-ray is unnecessary for abdominal complaints; NG tube placement is not indicated.
Understanding Advance Directives
- Advance directives specify treatment preferences for serious illness, directed by client’s wishes.
- Court cannot override informed consent unless client is deemed legally incompetent.
- They do not allow clients to withhold information or dictate emergency treatment protocols.
Insulin Mixing Procedure
- Correct procedure sequence: inject air into NPH, then regular insulin, and withdraw accordingly to prevent contamination.
Performing a Romberg Test
- A Romberg test checks balance; the client stands with arms and feet together to assess stability.
- Other tests mentioned assess sensory functions and renal evaluation, not balance.
Home Oxygen Concentrator Safety
- Routine checks for electrical cord integrity promote safe use of an oxygen concentrator.
- Family should observe for hypoxia signs and consider backup power sources to ensure oxygen availability.
- Maintain at least 10 feet distance from open flames and select non-static materials for safety.
Diet for Hypokalemia
- Recommend avocados as high-potassium options.
- Other foods like cucumbers, corn, and asparagus are low in potassium and less beneficial for the condition.
Administering Otic Medications
- Gently pressing on the tragus aids in delivering medication deeper into the ear.
- Correct positioning of the auricle is crucial for adults during ear medication administration.
Opioid Medication Protocol
- Witnessing a controlled substance wastage by a second nurse is required for compliance with regulations.
- Disposal protocols prohibit throwing controlled substances into sharps containers or locking medication inappropriately.
Adverse Effects Monitoring in IV Therapy
- Auscultating lung sounds is essential to monitor for fluid volume excess, a common complication of IV therapy.
- Assessing urine output and blood pressure are necessary but less urgent than evaluating lung sounds.
Managing Anger in Diagnosis
- Reassuring clients that their anger is a normal reaction facilitates coping with a cancer diagnosis.
- Avoid teaching future management during the anger phase; focus on listening to current feelings.
Physical Activity Recommendations for Osteoporosis
- Encourage brisk walking as a weight-bearing exercise beneficial for bone health prevention.
- Avoid non-weight-bearing activities like cycling and exercises that may cause injury due to low bone density.
Preventing Plantar Flexion Contractures
- Using ankle-foot orthotic devices maintains proper foot positioning to reduce contracture risks.
- Avoid placing pillows under knees or using slippers that do not affect foot alignment.
Incentive Spirometry After Surgery
- Priority is to understand the client’s reasons for refusing the incentive spirometer rather than immediately involving a specialist.
- This approach addresses psychosocial factors before advancing treatment discussions.### Health Restorative Activities
- Prioritize understanding the client's reasons for refusing incentive spirometer use before action.
- Documentation of refusal is essential but follows assessment.
- Administering pain medication may not address underlying reasons for treatment refusal.
Heparin Self-Administration
- Instruct clients to administer heparin into the abdomen, 5.08 cm (2 in) from the umbilicus.
- Needle should be inserted at a 45° to 90° angle, not 15°.
- No aspiration for blood return is necessary, as it can cause tissue damage.
- Do not massage the injection site to prevent bruising.
Change-of-Shift Report
- Focus on current breath sounds as the priority information in a pneumonia case.
- Admitting diagnosis, body temperature, and diagnostic test results are important but tertiary.
Inserting NG Tube
- Have the client sip water during NG tube insertion to help navigate the oropharynx.
- Ensure the client is in high-Fowler's position, with head of the bed at 90°.
- Withdraw, not fully remove, the tube if the client gags.
- Suction should only be applied post-placement, verified by x-ray.
Hearing Aid Usage
- Clients should remove hearing aids before showering to avoid water damage.
- Behind-the-ear hearing aids allow for volume fine-tuning, contrary to common misunderstanding.
- Whistling sounds when inserting may indicate an improper fit or ear blockage.
Walker Usage
- Address potential fall hazards at home, like overhanging trees.
- Place frequently used items within reach to prevent unnecessary movement at night.
- Avoid throw rugs as they increase fall risks.
Nasotracheal Suctioning
- Use intermittent suction while withdrawing the catheter to protect mucosa.
- Insert catheter during inhalation, not swallowing, to reduce risks.
- Discard suction catheters after use to prevent reintroducing pathogens.
Oxygen Therapy Administration
- Regulate flow via nasal cannula at a maximum of 6 L/min to prevent drying.
- Use water-soluble lubricant for skin, avoiding petroleum jelly.
- Ensure reservoir bag of partial rebreathing masks is adequately inflated during use.
Heparin Infusion Calculation
- Set the infusion pump for a heparin infusion at 8 mL/hr based on prescribed dosage.
Peripheral IV Complications
- Skin blanching at the IV site indicates infiltration; assess for this evidence.
- Exudate indicates infection, while warmth could signal phlebitis.
Elder Abuse Indicators
- A caregiver insisting on staying during assessments can indicate potential mistreatment.
- Having a financial power of attorney does not suggest elder abuse.
- Locking wheelchair wheels is a safety measure, not neglect.
Peripheral IV Catheter Insertion
- Position the client's arm dependently to promote vein dilation.
- Use a 10° to 15° angle for insertion in older adults, avoiding excessive hair shaving.
- Use veins other than the fragile hand veins for accessing IV therapy.
Wound Irrigation Practices
- Clean wounds from the center outward to prevent infection from surrounding skin.
- Use body temperature warm irrigation solution.
- Irrigate wounds with a 35-mL syringe for appropriate pressure.
Crutch Use Education
- Teach clients to shift weight to the unaffected leg when descending stairs.
- Crutches must not be placed 12 inches but rather about 15 cm (6 in) in front.
- Support crutches by holding both handles together before sitting.
Psychomotor Learning for Adolescents
- Engage in practice sessions to enhance skills related to surgical ostomy care techniques.
IV Infection Control
- Use a transparent dressing over the IV site to minimize infection risks.
- Avoid shaving near the IV site; clip hair as needed.
- Use chlorhexidine or povidone-iodine for site cleansing, not hydrogen peroxide.
Tracheostomy Care Education
- Recommend using tracheostomy covers outdoors for added protection.
- Remove the outer cannula is never appropriate; it supports the airway.
- Clean the site with sodium chloride, not hydrogen peroxide, to prevent irritation.### Spiritual Distress
- Requests to understand the cause of illness, such as "What could I have done to deserve this illness?" indicate spiritual distress, prompting a review of life's meaning.
- Statements reflecting blame towards medical science or questioning family presence indicate other forms of distress, not necessarily spiritual.
- Feelings of powerlessness do not equate to spiritual conflict.
Skin Cancer Assessment
- A mole with an asymmetrical appearance is a key indicator of potential skin malignancy.
- Uniform pigmentation in lesions is not typically associated with skin cancer.
- New petechiae and papules do not directly indicate skin malignancy.
Diabetes Education for Insulin Self-Administration
- The initial step in teaching a client about insulin self-administration is to determine the client’s learning style.
- Support persons can be included after assessing the client’s preferred learning method.
- Subsequent reinforcement can involve scheduling teaching sessions and providing written materials.
Fall Risk Management in Dementia
- Utilizing a bed exit alarm system is essential for safety in clients with dementia.
- Raising all side rails or applying restraints increases fall risk and should be avoided.
- Dimming room lights may reduce visibility, heightening fall risk.
Cane Usage
- Correct cane usage involves holding the cane on the stronger side for better support.
- The cane should be advanced 15 to 30 cm (6 to 12 in) rather than 46 cm (18 in) to maintain balance.
- The weaker leg should move forward in conjunction with the cane for proper weight distribution.
Suctioning Protocol for Tracheostomy
- Select a suction catheter that is half the size of the lumen to avoid injury and hypoxemia.
- Preoxygenation must utilize 100% oxygen before suctioning to prevent complications.
- Proper lubrication of the suction catheter is crucial, using sterile solutions rather than water-soluble lubricant.
Incident Response for Client Falls
- Assessing the client for injuries is the first step upon discovering a fall.
- Moving hazardous objects and documenting the event are important but come after initial assessment.
- Gathering information about the fall is important for future prevention.
Colon Cancer Screening
- Average-risk adults should start colorectal cancer screening at age 45 with annual fecal occult blood tests.
- Colonoscopy and sigmoidoscopy screening intervals differ; colonoscopy every ten years and sigmoidoscopy every five years for average-risk clients.
Postoperative Care for Knee Arthroplasty
- Ensure enough space under thigh-length sequential compression sleeves to prevent circulatory issues.
- Clients should be positioned in dorsal recumbent or semi-Fowler's for sleeve application.
- Setting the ankle pressure should be between 35 and 55 mm Hg for optimal therapeutic benefit.
Terminal Illness and Resuscitation Decisions
- Providing oxygen through a nasal cannula is permissible for comfort without violating living will directives.
- Staff must respect the documented wishes in living wills, allowing clients to change directives as desired.
- Intubation or other resuscitative measures contradict client wishes if stated in their advance directives.
Time Management in Nursing
- Prioritize tasks using the planning step of the nursing process to optimize time management.
- Completing tasks per client before moving to another reduces risk of error.
- Documentation should be timely to enhance care quality and safety.
Protective Isolation Education
- Clients in protective isolation should wear masks when leaving their hospital rooms to minimize infection risk.
- Daily bathing with antimicrobial soap is encouraged for hygiene.
- Limitations on visitors are advised to protect the client's health.
Fall Risk Assessment for Older Adults
- Assess pupil clarity for cataract detection as it affects fall risk visibility.
- Test visual fields and acuity to identify peripheral vision impairments that contribute to fall risk.
- Lacrimal apparatus and conjunctival assessment do not directly relate to immediate safety needs.
Monitoring Immobile Patients
- Erythema on pressure points is a major concern indicating potential skin breakdown.
- Regular fluid intake and routine bowel movements within reasonable ranges are acceptable.
- Vigilance against any signs of potential complications, such as pressure ulcers, is essential.
Infection Control Practices
- Clients with tuberculosis must be placed in negative-pressure rooms to prevent airborne transmission.
- Soiled linens should be bagged in fluid-resistant containers, not mesh bags.
- Standard precautions, rather than disposable items, are adequate for clients with HIV.
Safe Client Transfers
- Assess for orthostatic hypotension before transferring clients to prevent falls.
- Proper use of a gait belt can assist in safe transfers, following initial assessment.
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Description
Test your knowledge on nursing fundamentals including passive range-of-motion exercises and assessing peripheral IVs. This quiz also covers interventions for clients in isolation due to tuberculosis. Prepare to understand the intricacies of patient care and safety.
