RN Fundamentals 2016 A Flashcards

Questions and Answers

The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

True

Which of the following findings should the nurse report to the provider?

Creatinine 0.8 mg/dL

Sodium 143 mEq/L

BUN 15 mg/dL

Potassium 5.4 mEq/L (correct)

Which type of transmission precautions should the nurse initiate for a client who has varicella?

Contact

Droplet

Airborne (correct)

Protective environment

Which statement indicates that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this." Signup and view all the answers

Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube Signup and view all the answers

Which situation should the nurse manager identify as a violation of HIPPA guidelines?

A nurse asks another nurse to assist with her documentation. Signup and view all the answers

What action should the nurse take when preparing to suction secretions from a client with a new tracheostomy?

Select a suction catheter that is half the size of the lumen Signup and view all the answers

Which technique should the nurse use when performing a Romberg's test?

Have the client stand with her arms at her side and her feet together Signup and view all the answers

Which tool or document should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) Signup and view all the answers

What are manifestations of thrombophlebitis?

Swelling, redness, and tenderness in a calf muscle. Signup and view all the answers

When documenting the quality of the client's pain on an initial pain assessment, which statement should the nurse record?

The pain is like a dull ache in my stomach. Signup and view all the answers

Which action should the nurse take to ensure that otic medication reaches the inner ear?

Press gently on the tragus of the client's ear Signup and view all the answers

What is the nurse's priority assessment question before hygiene care for a new resident?

Are you able to help with your hygiene care? Signup and view all the answers

What should the nurse include in teaching clients with a Clostridium difficile infection?

Have family members wear a gown and gloves when visiting Signup and view all the answers

Which assessments should be used to identify an older adult client's risk for falls?

Visual fields Signup and view all the answers

What action should the nurse take when a client expresses anger over a colorectal cancer diagnosis?

Reassure the client that this is an expected response to grief Signup and view all the answers

What action should the nurse plan when inserting a peripheral IV catheter?

Place the client's arm in a dependent position Signup and view all the answers

To prevent self-injury, which action should the nurse take when lifting a bedside cabinet?

Stand close to the cabinet when lifting Signup and view all the answers

Which situation requires the nurse to complete an incident report?

A client with an IV infusion pump receives an additional 250 mL of IV fluid Signup and view all the answers

Which statement should the nurse manager include in teaching newly licensed nurses about medication documentation?

Use the complete name of the medication magnesium sulfate. Signup and view all the answers

What precaution should the nurse take for a client with a latex allergy?

Wrap monitoring cords with stockinette and tape them in case Signup and view all the answers

When inserting an NG tube, what action should the nurse take?

Have the client take sips of water to promote insertion of the NG tube into the esophagus Signup and view all the answers

Which transmission precaution should be indicated for a client with an abdominal wound and purulent drainage?

Contact precautions Signup and view all the answers

What action should the nurse take during wound irrigation?

Cleanse the wound from the center outward Signup and view all the answers

How often should antiembolic stockings be removed?

Remove the stockings at least once per shift Signup and view all the answers

What action should the nurse take when caring for a client with NG tube and open feedings?

Tell the client to keep the head of the bed elevated at least 30 degrees Signup and view all the answers

Which actions should the nurse take for a client with tuberculosis?

Place the client in a room with negative-pressure airflow Signup and view all the answers

What should the nurse do first when finding a client on the bathroom floor?

Check the client for injuries Signup and view all the answers

What type of role-performance stress might the partner of a client with dementia be experiencing?

Role overload Signup and view all the answers

What priority assessment should the nurse perform when administering IV fluids?

Auscultate lung sounds Signup and view all the answers

What does a blowing sound in the neck during assessment indicate?

Narrowed arterial lumen Signup and view all the answers

What should the nurse expect when assessing a client with vomiting and diarrhea for 3 days?

Rapid heart rate Signup and view all the answers

What statement indicates spiritual distress in a client with terminal liver cancer?

What could I have done to deserve this illness? Signup and view all the answers

What should the nurse do when performing open irrigation on a client's indwelling urinary catheter?

Subtract the amount of irrigant used from the client's urine output Signup and view all the answers

How should the nurse respond to a client refusing a blood transfusion for religious reasons?

Withhold the blood transfusion Signup and view all the answers

What should the nurse respond to a client asking about routine screening for colon cancer?

You should have a fecal occult blood test every year. Signup and view all the answers

What is the first intervention the nurse should take for a client having difficulty breathing?

Assist the client to an upright position Signup and view all the answers

Which action should the nurse take before administering 0.5 mL of oral liquid medication?

Gently shake the container of medication prior to administration Signup and view all the answers

What intervention should be included to improve self-feeding for a client with vision loss?

Use a clock pattern to describe food on the client's plate Signup and view all the answers

What type of physical activity should the nurse recommend for an older adult client at risk for osteoporosis?

Walking briskly Signup and view all the answers

What indicates that a client is ready to learn about insulin administration?

I can concentrate best in the morning. Signup and view all the answers

What statement by a client indicates understanding of oxygen therapy management at home?

I'll check the wires and cables on my TV to make sure they are in good working order. Signup and view all the answers

Which measure should the nurse recommend to a client reporting difficulty falling asleep?

Use progressive relaxation techniques at bedtime Signup and view all the answers

What position should the nurse place a postoperative client using an incentive spirometer?

Semi-Fowler's Signup and view all the answers

Which finding in a client who has been immobile for 3 weeks requires further intervention?

Erythema on pressure points Signup and view all the answers

Which statement by the client indicates understanding of a 24-hour urine collection?

I flushed what I urinated at 7:00 a.m. and have saved all urine since. Signup and view all the answers

Which complementary therapy is contraindicated for a client with herpes zoster?

Acupuncture Signup and view all the answers

Match the steps for transferring a client with right-sided weakness to a chair:

Ask the client if he can bear weight = 1 Position the chair on the left side of the bed = 2 Have the client sit and dangle his feet at the bedside = 3 Use the stand-and-pivot technique to move the client to the chair = 4 Signup and view all the answers

When administering an opioid medication from a vial, who should witness the wastage?

Another nurse Signup and view all the answers

At what rate should the nurse set the pump for a heparin infusion?

8 mL/hr Signup and view all the answers

Which step should a nurse remember when mixing regular and NPH insulin?

Inject air into cloudy insulin first Signup and view all the answers

What should the nurse prioritize when a client refuses to use an incentive spirometer?

Determine the reasons for refusal Signup and view all the answers

Which component of a medication prescription should the nurse question?

The dose Signup and view all the answers

What action should the nurse take to prevent skin breakdown in a client with limited mobility?

Have the client use a trapeze bar when changing position Signup and view all the answers

How should the nurse transcribe a verbal prescription for levothyroxine?

0.3 mg Signup and view all the answers

Which finding indicates infiltration at an IV site?

Skin blanching Signup and view all the answers

What action should the nurse take when administering multiple medications via an enteral feeding tube?

Flush the tube with 15 mL of sterile water Signup and view all the answers

Which teaching strategy should the nurse use with an older adult client?

Allow extra time for the client to respond Signup and view all the answers

Which action indicates the correct use of a cane by a client?

The client holds the cane on the stronger side of her body Signup and view all the answers

Which food item should be removed from a mechanical soft diet breakfast?

Fried egg Signup and view all the answers

What is the purpose of advance directives?

They indicate the form of treatment the client is willing to accept in the event of serious illness. Signup and view all the answers

Which finding should indicate a nurse that a client has developed thrombophlebitis?

Calf swelling Signup and view all the answers

Study Notes

Colon Cancer Screening

Routine screenings for average risk clients start at age 50.
Recommended screening options include a fecal occult blood test annually and colonoscopy every 10 years.

Respiratory Interventions

For clients in respiratory distress, prioritize non-invasive methods like assisting them to an upright position.

Medication Administration

Always gently shake liquid medications before administration.
High-Fowler's position is recommended for better medication absorption.

Vision Loss Adaptations

Describe food placement using a clock pattern to help clients with vision loss during meals.

Osteoporosis Prevention

Encourage regular, brisk walking as a weight-bearing activity to prevent osteoporosis.

Diabetes Education Readiness

A statement indicating the client can concentrate best in the morning reflects readiness to learn about insulin administration.

Oxygen Therapy Management

Clients should understand to keep smoking at least 6 feet away from oxygen sources and use safe materials like cotton for blankets.

Sleep Improvement Techniques

Suggest progressive relaxation techniques at bedtime to help clients with sleep difficulties.

Incentive Spirometry Positioning

Clients should be placed in a semi-Fowler's position to effectively use an incentive spirometer after abdominal surgery.

Pressure Ulcer Prevention

Erythema on pressure points signals the need for immediate intervention to relieve pressure.

24-Hour Urine Collection

Proper understanding includes discarding the first void and saving all subsequent urine, keeping it on ice.

Herpes Zoster and Complementary Therapy

Acupuncture is contraindicated for clients with herpes zoster to prevent infection risk.

Mobility Assistance

Use a trapeze bar to assist clients with limited mobility when changing positions to prevent skin breakdown.

Medication Transcription Accuracy

Proper transcription includes the unit of measurement for dosages, e.g., "0.25 mg" for digoxin.

IV Infiltration Indicators

Skin blanching, along with coolness and edema at the IV site, indicates infiltration.

Enteral Feeding Tube Medication Administration

Flush the tube with sterile water before and between medications; each medication should be dissolved separately.

Teaching Strategies for Older Adults

Allow extra time for responses due to slower information processing in older adults; encourage connection to past experiences.

Cane Use Assessment

Correct cane use involves holding it on the stronger side of the body to maintain balance.

Mechanical Soft Diet Considerations

Remove fried eggs from a mechanical soft diet; poached or scrambled eggs are acceptable alternatives.

Purpose of Advance Directives

Advance directives specify the types of treatment a client wishes to receive during serious illness.

Thrombophlebitis Symptoms

Manifestations include calf swelling, redness, and tenderness; monitor closely for these signs in immobile clients.

Pain Assessment Documentation

Document the quality of client's pain with descriptive statements, such as it being a "dull ache."

Otic Medication Administration

To ensure proper administration, press gently on the tragus and hold the ear in the correct position post-instillation.

Hygiene Care Preferences

Before performing hygiene care, assess the resident’s preference for bathing times and styles to ensure comfort.### Hygiene Care Assessment
Assessing client's ability to assist with hygiene is crucial to prevent injuries.
Overestimation of self-care abilities poses safety risks to clients.

Clostridium Difficile Infection Care

Family members should wear gowns and gloves during visits to infected clients.
Soap and water are necessary for hand hygiene; alcohol-based sanitizers do not kill C. difficile spores.
Clean contaminated surfaces using a phenol solution.

Risk for Falls in Older Adults

Assess pupil clarity, visual fields, and visual acuity for fall risk identification.
Cloudy pupils may indicate cataracts, increasing fall risk.
Visual acuity assessed using a Snellen chart.

Supporting Clients with Anger in Diagnosis

Reassure clients expressing anger that it's a normal grief response.
Support is essential for clients adjusting to serious diagnoses like colorectal cancer.

Peripheral IV Catheter Insertion

Position client's arm in a dependent position to aid vein dilation.
Use a 10 to 30-degree angle for catheter insertion.
Avoid shaving the area; clipping is safer to prevent skin breaks.

Safe Lifting Techniques

Stand close to objects being lifted to reduce back strain and maintain balance.
Avoid bending at the waist and using back muscles to lift; utilize leg strength instead.

Incident Reporting

Report a malfunction of IV infusion pumps; it's vital for risk management.
Adequate documentation is necessary for effective incident reviews.

Medication Documentation in Nursing

Use complete medication names to avoid confusion; e.g., "magnesium sulfate."
Avoid abbreviations that could lead to misinterpretation.

Latex Allergy Precautions

Use non-latex barriers for monitoring devices on clients with latex allergies.
Avoid direct contact with latex products to prevent allergic reactions.

NG Tube Insertion

Instruct clients to sip water during tube insertion to help with placement.
Position the client at a high-Fowler's angle to minimize aspiration risk.

Transmission Precautions for Infections

Apply contact precautions for clients with wound infections.
Ensure isolation in private rooms and use protective gear during care.

Wound Irrigation Techniques

Cleanse wounds from center outward to prevent contamination.
Maintain sterile techniques during irrigation procedures.

Antiembolic Stockings

Remove stockings at least once per shift to assess skin integrity and circulation.
Ensure stockings are applied correctly to avoid creases that may cause irritation.

NG Tube Feedings

Keep the head of the bed elevated to prevent aspiration during feedings.
Prioritize positioning over other preparatory actions in feeding procedures.

Tuberculosis Precautions

Implement airborne precautions in negative-pressure rooms for TB clients.
Wear appropriate protective equipment during care for infected individuals.

Fall Assessment Protocol

Priority action when finding a client on the floor is to check for injuries first.
Ensure a safe environment around clients to prevent further incidents.

Role-Performance Stress

Identify caregiver stress, like role overload, when responsibilities exceed personal capacity.
Support systems can assist in managing caregiving challenges for clients with dementia.

Monitoring IV Fluid Therapy

Auscultate lung sounds as a priority assessment to detect fluid-volume excess.
Monitor for respiratory symptoms related to fluid overload, such as crackles or dyspnea.

Identifying Vascular Issues

Arterial bruits indicate narrowed arterial lumen; assess for cardiovascular health.
Implementation of regular vascular assessments is crucial for timely interventions.

Assessing Fluid and Electrolyte Status

Rapid heart rate is an expected finding in clients with recent vomiting and diarrhea indicating fluid volume deficit.
Report abnormal electrolyte levels, particularly elevated potassium, as they may lead to serious complications.

Managing Spiritual Distress

Expressions of guilt regarding illness can indicate spiritual distress.
Supportive dialogue can help assess the psychological and emotional state of terminally ill clients.

Indwelling Catheter Irrigation Protocol

Subtract irrigant volume from urine output for accurate fluid management.
Adhere to established guidelines for catheter care to ensure client safety.

Autonomy in Client Care

Respect client autonomy by withholding medical interventions like blood transfusions if refused.
Uphold ethical standards in nursing by supporting client decisions regarding their treatment.

HIPAA Violations in Nursing

Discussing patient information with individuals not directly involved in care violates HIPAA guidelines.
Ensure confidentiality through controlled access to personal health information.

Tracheostomy Suctioning Procedure

Select suction catheter size carefully; half the size of the lumen is recommended.
Preoxygenate the client before suctioning to mitigate hypoxemia risk during the procedure.### Suction Catheter Guidelines
Select a suction catheter that is half the size of the lumen to minimize risks of hypoxemia and mucosal trauma.
Lubricate the end of the suction catheter using sterile water or 0.9% sodium chloride irrigation for reduced mucosal injury.
Set suction pressure to approximately 120 mmHg, ensuring it does not exceed 150 mmHg to protect against hypoxemia and trauma.

Romberg's Test Procedure

Perform Romberg's test to evaluate balance by having the client stand with arms at the sides and feet together.
Observe the client for any swaying or loss of balance during the test.

Change-of-Shift Report Tools

Utilize the Situation, Background, Assessment, and Recommendation (SBAR) tool for effective continuity of care communication.
Critical pathways aid in interprofessional care planning and are not used for shift reports.
Use a transfer report when a client moves between healthcare settings.
The Medication Administration Record (MAR) is essential for documenting medication administration.

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Test your nursing knowledge with these flashcards focusing on RN fundamentals from 2016. This quiz covers essential topics in patient care, including screening recommendations and advice for adult clients. Enhance your understanding and readiness for clinical scenarios with these informative questions.