Podcast
Questions and Answers
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the following indicates the correct number of mL the nurse should administer? (round answer to the nearest whole number.)
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the following indicates the correct number of mL the nurse should administer? (round answer to the nearest whole number.)
A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose and I'm worried I will lose it if it falls off." Which of the following is an appropriate response by the nurse?
A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose and I'm worried I will lose it if it falls off." Which of the following is an appropriate response by the nurse?
A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints?
A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints?
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
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A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
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A nurse is speaking with a client who has recently received a diagnosis of a chronic illness. The client states, "The doctor must be wrong. I can't be that sick." The nurse should inform the client that their reaction is an example of which of the following expected responses to grief?
A nurse is speaking with a client who has recently received a diagnosis of a chronic illness. The client states, "The doctor must be wrong. I can't be that sick." The nurse should inform the client that their reaction is an example of which of the following expected responses to grief?
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A Nurse on a medical-surgical unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?
A Nurse on a medical-surgical unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?
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A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the clients indicates an understanding of the teaching?
A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the clients indicates an understanding of the teaching?
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A nurse is preparing to transfer a client who is partially weight bearing from the bed to the chair. Which of the following actions should the nurse take?
A nurse is preparing to transfer a client who is partially weight bearing from the bed to the chair. Which of the following actions should the nurse take?
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A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take?
A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take?
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A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the following finding is the nurse's priority?
A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the following finding is the nurse's priority?
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A nurse is caring for a client who has been treated multiple times for STIs. Which of the following responses should the nurse take?
A nurse is caring for a client who has been treated multiple times for STIs. Which of the following responses should the nurse take?
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A nurse is documenting client care. Which of the following abbreviations should the nurse use?
A nurse is documenting client care. Which of the following abbreviations should the nurse use?
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A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?
A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?
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A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make?
A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make?
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A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take?
A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take?
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A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet?
A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet?
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A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history?
A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history?
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A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?
A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?
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A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity?
A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity?
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A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?
A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?
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A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula?
A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula?
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A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements but the client indicates an understanding of the teaching
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements but the client indicates an understanding of the teaching
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A nurse is assessing the body temperature of an adult client using a temporal artery thermometer. Which of the following actions should the nurse take? (Select all that apply)
A nurse is assessing the body temperature of an adult client using a temporal artery thermometer. Which of the following actions should the nurse take? (Select all that apply)
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A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the following actions should the nurse take to help dilate the vein?
A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the following actions should the nurse take to help dilate the vein?
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A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
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A nurse is testing a client for conduction deafness by performing Weber's test. Which of the following actions should the nurse take when performing this test?
A nurse is testing a client for conduction deafness by performing Weber's test. Which of the following actions should the nurse take when performing this test?
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A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify which of the following medications can interact adversely with this supplement?
A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify which of the following medications can interact adversely with this supplement?
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A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take?
A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take?
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A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
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A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?
A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?
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A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, "I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse?
A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, "I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse?
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A Nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?
A Nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?
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A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team.
A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team.
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A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse indicates an understanding of the teaching?
A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse indicates an understanding of the teaching?
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A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan?
A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan?
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A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?
A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?
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A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take?
A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take?
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A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?
A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?
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A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag?
A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag?
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During change of shift report, a nurse discovers she overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?
During change of shift report, a nurse discovers she overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?
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A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag?
A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag?
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A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula?
A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula?
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A nurse is caring for a client immediately following the insertion of an NG tube. Which of the following should indicate to the nurse that the tube is placed incorrectly?
A nurse is caring for a client immediately following the insertion of an NG tube. Which of the following should indicate to the nurse that the tube is placed incorrectly?
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A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube?
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube?
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A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain meds are not an option for managing pain. Which of the following is an appropriate response by the nurse?
A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain meds are not an option for managing pain. Which of the following is an appropriate response by the nurse?
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A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
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A nurse is caring for a client who is immunocompromised which of the following actions should the nurse take?
A nurse is caring for a client who is immunocompromised which of the following actions should the nurse take?
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Which of the following veins should the nurse select when initiating iv therapy?
Which of the following veins should the nurse select when initiating iv therapy?
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Interventions should the nurse take to prevent skin breakdown?
Interventions should the nurse take to prevent skin breakdown?
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Client tells the nurse" I am looking forward to seeing my grandchildren grow up." the nurse should identify the client is experiencing which of the following stages of grief?
Client tells the nurse" I am looking forward to seeing my grandchildren grow up." the nurse should identify the client is experiencing which of the following stages of grief?
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A nurse is teaching a client about the care and use of hearing aids. Which of the following instructions should the nurse include in the teaching?
A nurse is teaching a client about the care and use of hearing aids. Which of the following instructions should the nurse include in the teaching?
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A nurse is teaching a client about the care and use of hearing aids. Which of the following should the nurse take?
A nurse is teaching a client about the care and use of hearing aids. Which of the following should the nurse take?
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A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching?
A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching?
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A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take?
A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take?
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A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?
A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?
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A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the
following information should be included in the teaching? (select all that apply)
A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should be included in the teaching? (select all that apply)
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A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first?
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first?
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A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?
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A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)
A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)
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A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
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A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statement by the client partner indicates maladaptive coping?
A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statement by the client partner indicates maladaptive coping?
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A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?
A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?
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A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?
A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?
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A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?
A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?
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A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply
A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply
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A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?
A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?
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A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?
A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?
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A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?
A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?
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A nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?
A nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?
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A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?
A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?
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A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?
A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?
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A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
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A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
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A nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don't understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take?
A nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don't understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take?
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A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts?
A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts?
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An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?
An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?
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A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
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A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?
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A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
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continue with question 84 on quilzlet.
continue with question 84 on quilzlet.
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Study Notes
Medication Administration & Calculation
- Diphenhydramine 20 mg oral dose for a 6-year-old needing oral syrup (12.5 mg/5 ml): 8 ml needed.
Client Safety & Restraints
- For a malnourished client, place a loose wedding ring in a locked storage unit.
- Restraints should only be used when the client poses a threat to self.
Ethical Dilemmas & Informed Consent
- An ethical dilemma arises when a family requests not to disclose a terminal diagnosis.
- Document a client's decision not to proceed with a surgical procedure.
Nursing Roles & Responsibilities
- Nurse managers function as client advocates when supervising procedures like catheterization.
- A nurse educator should teach newly hired nurses about the abrupt onset of delirium.
Client Responses to Diagnosis
- Clients denying a diagnosis of a chronic illness are exhibiting a grief response of denial.
Wound Care & Post-Op Care
- Clean a wound site with a different sterile swab for each stroke.
Post-Op Care & Medications
- When administering medications via IV bolus, select the injection port closest to the client, clean it, aspirate for blood return, then inject the medication, in this specific order.
Diabetic Care
- Roll the NPH insulin vial before drawing it.
- Never inject air into the regular insulin vial first.
Client Assessment
- Use the temporal artery thermometer's probe to slide across the forehead and hold the client's hair aside.
- Document the temperature with "AX".
- Dangle the client's arm over the bed to dilate the vein for IV insertion.
Respiratory & Suctioning
- When suctioning, hyperoxygenate the client for 30-60 seconds before each pass.
- Apply intermittent suction during catheter insertion
Pain Management & Priorities
- Respiratory rate, especially a rate of 7/min, is a priority finding when assessing a client who received morphine recently.
Client Education & Support
- Avoid making judgmental comments or giving unsolicited advice when addressing recurrent STIs in clients.
- If possible, explore the causative factors.
- If a client refuses to follow prescribed treatment, document their decision.
- For clients with terminal illnesses, encourage open discussion about their needs and concerns.
- Encourage clients to share their life stories to promote dignity.
- Clients experiencing insomnia should be encouraged to consume a light carbohydrate snack prior to bed.
Immobility & Skin Integrity
- Encourage active movements and exercises to address immobility complications.
- Avoid placing immobile clients in harmful situations or postures.
- Change client position every 4 hrs for immobility risks.
- Prevent skin breakdown by applying moisture barrier ointments after hygiene procedures.
- Avoid friction and pressure on skin when cleaning clients.
- For clients prone to urinary incontinence, use of an indwelling urinary cath should be considered to prevent skin breakdown
Discharge Planning
- Review the client's medication reconciliation with the client thoroughly.
- Help a client obtain needed insulin supplies, as financial challenges can impede proper care.
- Provide contact information for a diabetes education specialist, and printed material on insulin management.
Infection Control & Isolation
- Wear a mask and a gown when treating a client requiring isolation.
- Assign clients with MRSA infections to a private room with positive airflow.
Allergy Precautions
- Cover blood pressure cuffs with stockinette when a client has a latex allergy.
- Use non-latex gloves and syringes when providing care.
- Remove the stopper to help prevent latex exposure.
Surgical Preparation & Consent
- Notify the provider if the client expresses lack of understanding about a surgical procedure.
- When a client is confused or expresses concern, use communication skills to calm and provide adequate explanation.
Patient Care & Observation
- Confirm the client's identity before administering medications.
- To identify client, use client's phone #.
- If a client's pain level remains high, suggest a pain management technique.
- Assess fluid balance to discover dehydration or fluid overload.
Client Education
- Encourage an immunocompromised client to practice hand hygiene with alcohol-based hand rubs.
- Encourage the client's family, visitors to wear masks who are within 3 feet of the client.
IV Insertion
- Select the cephalic vein in the left distal forearm for IV insertion, especially for older adult clients.
- Position the client's arm so the vein is appropriately located before proceeding with IV placement.
Wound Drainage
- When dealing with a closed drainage system, press straight down on the container, not the drainage port, to create a vacuum.
Documentation
- Use abbreviations appropriate to the context and standardized guidelines when documenting client care (e.g., "BRP" for bathroom privileges).
- Avoid using abbreviations that have more than one meaning.
Client Transfer
- Have the client bear weight on their stronger leg when transferring.
- Position the chair next to the bed at a 90-degree angle for ease of transfer.
Diagnostic Procedures
- Ensure a client undergoing an IVP is free of metal objects.
- Consider bowel cleansing for an IVP.
Client Assessment & Intervention
- When assessing bowel sounds, listen using the diaphragm of the stethoscope.
- Assess the color, appearance, and tenderness of the abdomen visually before performing palpation when abdominal pain is mentioned.
Communication & Support
- A client with communication issues should be advised and provided information in an approachable manner and with clear, direct language.
Pressure Ulcer Prevention
- Assess a pressure ulcer (or any skin issue) for blanching to discern the stage of wound.
- Reposition clients regularly, particularly those who are immobile / bed-bound for extended time periods.
Hearing Aids
- Turn the hearing aid off and lower the volume before insertion and when storing.
Speech Therapy
- Explain esophageal speech techniques to a client scheduled for a total laryngectomy.
Home Safety
- Use electrical tape to secure extension cords.
- Have a fire escape plan with family members.
- Keep medications away from reach of children, check their expiration dates.
Restraints & Assessment
- Remove restraints one at a time.
- Assess peripheral pulses before and during restraints removal.
Infection Control (Additional Details)
- Place clients with C. diff in a private room.
- Wear gown and gloves.
- Use soap and water to wash hands.
- Use an N95 mask should be used for airborne isolation
Post-Surgery Complications
- If a post-operative client reports new and severe abdominal pain, visually inspect the abdomen for any changes in appearance.
Ophthalmic Solutions
- After instilling eye drops, press the inner corner of the eye to prevent the eye drop or medicine from coming out.
- Do not let clients touch the dropper on anything to avoid contamination.
- Close eyes for a few minutes
Delegation
- Delegate tasks that don't require advanced judgment to assistive personnel when appropriate.
Wound Care (Details)
- Use a different, sterile swab for each stroke during wound cleaning.
Patient Positioning
- If a client reports lack of sleep due to a night shift, recommend listening to soft music or environmental sounds to relax prior to bedtime.
Treatment Options
- If a client wishes to use alternative treatment methodologies like traditional Chinese medicine, ask their provider for recommendations or allow for further discussion/exploration between the client and their doctor
Enteral Feedings
- Check for gastric residual volume before administering enteral feedings.
- If possible, confirm correct NG tube placement by checking pH or aspirating.
- When possible, check for bowel sounds before placing an NG tube.
Pain Management
- Suggest a massage or other soothing techniques for clients who wish not to use medications.
Fluid Volume Deficit
- A client with an extracellular fluid deficit may exhibit postural hypotension.
Central Venous Lines
- Central venous lines are often needed for long-term, continuous parental nutrition.
Pressure Ulcers
- Assess for blanching to determine the stage of a pressure ulcer.
Kegel Exercises
- During Kegel exercises, tighten the pelvic floor muscles to be effective.
Skin Assessment (Specifics)
- If a client reports skin changes noted by clients over long periods of their working lives, monitor skin for any changes and unusual occurrences.
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Description
Test your understanding of essential nursing principles and practices, including medication administration, client safety, ethical dilemmas, and wound care. This quiz covers vital aspects of nursing roles and responsibilities necessary for effective patient care. Prepare yourself for real-life scenarios faced in the nursing profession.