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A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
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A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
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A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
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A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
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A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
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A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
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A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.
A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.
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A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
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A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
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A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
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A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?
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A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
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A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?
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A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
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A nurse in a medical-surgical unit is caring for six clients. Complete the following sentence by using the lists of options.
A nurse in a medical-surgical unit is caring for six clients. Complete the following sentence by using the lists of options.
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A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
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A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?
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A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
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Study Notes
Discharge Summaries & Documentation
- Discharge summaries must contain current medications for client safety and continuity of care.
Tracheostomy Suctioning
- Select a suction catheter half the size of the tracheostomy lumen to prevent hypoxemia and trauma.
Plantar Flexion Contractures
- Use ankle-foot orthotics or footboards to maintain dorsiflexion and prevent contractures.
HIPAA Compliance
- Nurses should not ask others to assist with client documentation as it violates HIPAA (client information access limited to direct care providers).
- Only health care professionals directly caring for a client should have access to the client's medical information.
Oral Medication Administration
- Gently shake liquid medications to ensure proper mixing before administration.
Medication Reconciliation
- Compare prescribed medications with those received at the facility during discharge for accurate medication lists.
- Create current, accurate list of every medication the client is or should be taking.
Spiritual Distress
- A client expressing "What could I have done to deserve this illness?" suggests spiritual distress.
- A client's terminal illness prompts the client to review their life and question its meaning.
Insulin Administration
- Inject air into the NPH insulin vial first, then the regular insulin vial. Withdraw regular insulin, then NPH insulin.
- Inject air into the vial of NPH insulin without touching the needle to the solution.
- Inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin.
- Insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin.
Dehydration Assessment
- Clients with vomiting and diarrhea often exhibit tachycardia (rapid heart rate).
Client Transfer
- Assess for orthostatic hypotension before assisting a client who can bear weight on one leg to stand to prevent falls.
- The first action the nurse should take when using the nursing process is to assess the client. Determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.
Pneumonia Assessment & Intervention
- Streptococcal pharyngitis requires an antibiotic prescription, droplet precautions (including masking when within 1 meter of the client), and reporting the findings.
- Address respiratory problems (O2, cough, fever, isolation precautions), including droplet isolation, oxygen, and antipyretics when needed.
Fluid Intake Documentation
- Document ice chips as half their volume in mL when calculating intake to account for the air between the chips. 1 cup water ≈ 240 mL.
Veracity
- Veracity is upholding honesty and truthfulness in client interactions (eg. answering honestly regarding client's issues).
IV Fluid Monitoring
- Auscultating for lung sounds is the priority when monitoring for fluid volume excess.
IV Infiltration
- Blanching, swelling, and coolness at the IV site indicate infiltration.
Aromatherapy & Contraindications
- Essential oils may trigger bronchospasm, requiring provider consultation.
Elder Abuse Indicators
- A caregiver who insists on remaining in the room during an admission assessment is a potential indicator of abuse.
Vision Loss & Feeding
- Arrange food on the client's plate in a consistent pattern to help with self-feeding.
Client Prioritization
- Assess the client with the lowest oxygen saturation first, then clients with abnormal potassium levels; acute needs come first.
- Priority client is the one with oxygen saturation that is less than the expected reference range because this is an indication of hypoxia. Next priority client is the one with potassium level that is less than the expected reference range which places the client at risk for dysrhythmias.
Medication Dosage Transcription
- When documenting a medication dose, include the unit of measurement (mg, mcg), for instance, 0.3 mg levothyroxine, not only 0.3.
- Zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.
Colon Cancer Screening
- Annual fecal occult blood tests are recommended for adults at average risk of colorectal cancer, starting at age 50.
Shift Report Priority
- Provide the client's current breath sounds when reporting on ventilation concerns.
Pressure Injury Reporting
- Report fever, elevated WBC counts, increasing pain, purulent or foul-smelling drainage of pressure injuries to the provider for intervention and treatment.
- Include findings indicating infection (e.g., fever, elevated WBC counts).
- Include pain level increase.
Sleep Disturbances
- Maintain a regular sleep-wake schedule to improve sleep quality.
Osteoporosis Prevention
- Recommend brisk walking as a weight-bearing exercise to maintain bone density.
Spinal Cord Injury & Pressure Injuries
- Perform passive range-of-motion exercises two to three times each day to reduce the risk for contractures.
- Monitor for pressure injuries (staging, contractures, erythema) to prevent complications.
- Apply foot boots to the client's feet to protect the client's heels and promote healing.
RN Scope of Practice
- An RN can initiate enteral feedings.
NG Tube Feeding
- Position the client with their head of bed elevated to prevent aspirating enteral formula.
Latex Allergy Precautions
- Use non-latex cords and items to avoid exposure.
Abdominal Pain & Enema
- Position the client on their left side with their right knee bent, auscultate bowel sounds, and perform a digital rectal examination prior to enema administration.
Pain Assessment Documentation
- Record how the pain feels (dull ache, sharp stabbing) rather than descriptors like "mild", "moderate", or "severe.
Heparin Infusion Calculation
- Calculate the infusion rate by dividing the desired hourly dosage in units by the total units of medication in the infusion bag (250 mL).
- 8 mL/hr if desired infusion rate is 800 units per hour.
Informed Consent
- The nurse's role is to witness the client sign the consent form after ensuring understanding and competency.
Tuberculosis Precautions
- Implement airborne and standard precautions (mask & gloves). Negative pressure rooms are essential to limit transmission.
Medication Prescription Verification
- Ensure correct units of measurement (mg, mcg) are included in prescriptions as 0.25 should be followed by mg or mcg.
24-Hour Urine Collection
- Discard the initial urine and collect all subsequent urine samples for a 24-hour period.
PCA Pump Management
- The nurse should educate clients and families not to activate the PCA button when the client is asleep to prevent medication overuse.
Romberg Test
- Have the client stand with feet together and arms at sides to assess balance.
Delegating to APs
- Post-operative ambulation is within the scope of an AP.
Fire Safety
- Implement RACE (rescue, activate alarm, contain fire, extinguish). Evacuate clients first.
Malnutrition Signs
- Look for symptoms like wasting, fatigue, dry/scaly skin, thin/sparse hair, edema.
Senior Adult Health
- Recommend vaccines (pneumococcal for 65+), and regular eye checks. Check the vaccine schedule for various diseases
Fluid Volume Excess
- Distended neck veins, edema, and tachycardia are indications of fluid volume excess, a complication of IV therapy.
Clostridium difficile Precautions
- Employ contact precautions and implement measures to prevent transmission of spores, including wearing gowns and gloves by both staff and visitors.
Ostomy Care Priority
- Assess the severity level of wound and stoma color change (necrosis), followed by observing the surrounding skin and pouch seal integrity for potential infection risk.
- The greatest risk to the client is the necrosis of the bowel.
- If stoma is dark purple, blistering is present, and pouch is leaking, notify the provider.
- Assess skin around stoma to identify infection risk.
Herbal Supplement Use
- Echinacea is often recommended for immune support, while others have alternative uses, but consult with provider before use.
Tuberculosis PPE
- Wear an N95 respirator when providing care to a client with tuberculosis.
Ostomy Client Teaching Methods
- Utilize practice sessions to provide clients with psychomotor skills training related to their ostomy.
Hypertension Risk Factors
- Smoking increases the risk of high blood pressure and other health complications.
Sterile Field Preparation
- Avoid placing the caps of sterile solution bottles onto the sterile field (keep unsterile surface facing down). Ensure that the sterile items are held safely away from the edges of the sterile field.
Advance Directives
- Instruct clients to discuss advance directives with their provider and offer to provide client-friendly literature or resources.
Chemotherapy Client Risks
- The client may be at risk for bleeding due to low platelet count, and infection from a weak immune system.
- Monitor platelet count.
Middle Adulthood & Generativity
- Encourage clients to find ways to mentor or guide others, which can ease feelings of uselessness, offering purpose in middle adulthood.
Blood Pressure Measurement
- Inflate the blood pressure cuff 30 mm Hg above the last palpable pulse point.
Peripheral Vascular Sounds
- A bruit (blowing sound) indicates narrowed artery lumen.
Medication Administration with Enteral Feeding Tubes
- Flush the tube with appropriate amounts of sterile water before and after medication administration to prevent clogging.
- Flush with 15 to 30 mL of sterile water before and between medications.
- Flush with 30 to 60 mL following last med.
Blood Transfusion Refusal
- Respect the client's autonomy and do not administer the transfusion if the client refuses, even if the partner desires otherwise.
Oxygen Concentrator Safety
- Keep oxygen concentrators away from flammable materials, routinely check cords for damage, and consider a generator for power outages.
Crutch Use Instruction Verification
- The client understands proper crutch use when they mention shifting their weight to the unaffected leg during stairs descent.
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Description
Test your knowledge on essential nursing practices including discharge summaries, medication administration, and HIPAA compliance. This quiz covers crucial aspects of patient care that ensure safety and legal adherence in healthcare settings.
