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Questions and Answers
The principle of autonomy ensures that a client who is competent has the right to refuse treatment.
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?
Which of the following findings should the nurse report to the provider?
Which type of transmission precautions should the nurse initiate for a client who has varicella?
Which type of transmission precautions should the nurse initiate for a client who has varicella?
Which statement indicates that the client's family member is coping effectively with the situation?
Which statement indicates that the client's family member is coping effectively with the situation?
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Which of the following interventions should the nurse include that is within the RN scope of practice?
Which of the following interventions should the nurse include that is within the RN scope of practice?
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Which situation should the nurse manager identify as a violation of HIPPA guidelines?
Which situation should the nurse manager identify as a violation of HIPPA guidelines?
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What action should the nurse take when preparing to suction secretions from a client with a new tracheostomy?
What action should the nurse take when preparing to suction secretions from a client with a new tracheostomy?
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Which technique should the nurse use when performing a Romberg's test?
Which technique should the nurse use when performing a Romberg's test?
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Which tool or document should the nurse use to communicate continuity of care?
Which tool or document should the nurse use to communicate continuity of care?
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What are manifestations of thrombophlebitis?
What are manifestations of thrombophlebitis?
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When documenting the quality of the client's pain on an initial pain assessment, which statement should the nurse record?
When documenting the quality of the client's pain on an initial pain assessment, which statement should the nurse record?
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Which action should the nurse take to ensure that otic medication reaches the inner ear?
Which action should the nurse take to ensure that otic medication reaches the inner ear?
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What is the nurse's priority assessment question before hygiene care for a new resident?
What is the nurse's priority assessment question before hygiene care for a new resident?
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What should the nurse include in teaching clients with a Clostridium difficile infection?
What should the nurse include in teaching clients with a Clostridium difficile infection?
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Which assessments should be used to identify an older adult client's risk for falls?
Which assessments should be used to identify an older adult client's risk for falls?
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What action should the nurse take when a client expresses anger over a colorectal cancer diagnosis?
What action should the nurse take when a client expresses anger over a colorectal cancer diagnosis?
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What action should the nurse plan when inserting a peripheral IV catheter?
What action should the nurse plan when inserting a peripheral IV catheter?
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To prevent self-injury, which action should the nurse take when lifting a bedside cabinet?
To prevent self-injury, which action should the nurse take when lifting a bedside cabinet?
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Which situation requires the nurse to complete an incident report?
Which situation requires the nurse to complete an incident report?
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Which statement should the nurse manager include in teaching newly licensed nurses about medication documentation?
Which statement should the nurse manager include in teaching newly licensed nurses about medication documentation?
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What precaution should the nurse take for a client with a latex allergy?
What precaution should the nurse take for a client with a latex allergy?
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When inserting an NG tube, what action should the nurse take?
When inserting an NG tube, what action should the nurse take?
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Which transmission precaution should be indicated for a client with an abdominal wound and purulent drainage?
Which transmission precaution should be indicated for a client with an abdominal wound and purulent drainage?
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What action should the nurse take during wound irrigation?
What action should the nurse take during wound irrigation?
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How often should antiembolic stockings be removed?
How often should antiembolic stockings be removed?
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What action should the nurse take when caring for a client with NG tube and open feedings?
What action should the nurse take when caring for a client with NG tube and open feedings?
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Which actions should the nurse take for a client with tuberculosis?
Which actions should the nurse take for a client with tuberculosis?
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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 type of role-performance stress might the partner of a client with dementia be experiencing?
What type of role-performance stress might the partner of a client with dementia be experiencing?
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What priority assessment should the nurse perform when administering IV fluids?
What priority assessment should the nurse perform when administering IV fluids?
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What does a blowing sound in the neck during assessment indicate?
What does a blowing sound in the neck during assessment indicate?
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What should the nurse expect when assessing a client with vomiting and diarrhea for 3 days?
What should the nurse expect when assessing a client with vomiting and diarrhea for 3 days?
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What statement indicates spiritual distress in a client with terminal liver cancer?
What statement indicates spiritual distress in a client with terminal liver cancer?
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What should the nurse do when performing open irrigation on a client's indwelling urinary catheter?
What should the nurse do when performing open irrigation on a client's indwelling urinary catheter?
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How should the nurse respond to a client refusing a blood transfusion for religious reasons?
How should the nurse respond to a client refusing a blood transfusion for religious reasons?
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What should the nurse respond to a client asking about routine screening for colon cancer?
What should the nurse respond to a client asking about routine screening for colon cancer?
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What is the first intervention the nurse should take for a client having difficulty breathing?
What is the first intervention the nurse should take for a client having difficulty breathing?
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Which action should the nurse take before administering 0.5 mL of oral liquid medication?
Which action should the nurse take before administering 0.5 mL of oral liquid medication?
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What intervention should be included to improve self-feeding for a client with vision loss?
What intervention should be included to improve self-feeding for a client with vision loss?
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What type of physical activity should the nurse recommend for an older adult client at risk for osteoporosis?
What type of physical activity should the nurse recommend for an older adult client at risk for osteoporosis?
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What indicates that a client is ready to learn about insulin administration?
What indicates that a client is ready to learn about insulin administration?
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What statement by a client indicates understanding of oxygen therapy management at home?
What statement by a client indicates understanding of oxygen therapy management at home?
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Which measure should the nurse recommend to a client reporting difficulty falling asleep?
Which measure should the nurse recommend to a client reporting difficulty falling asleep?
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What position should the nurse place a postoperative client using an incentive spirometer?
What position should the nurse place a postoperative client using an incentive spirometer?
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Which finding in a client who has been immobile for 3 weeks requires further intervention?
Which finding in a client who has been immobile for 3 weeks requires further intervention?
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Which statement by the client indicates understanding of a 24-hour urine collection?
Which statement by the client indicates understanding of a 24-hour urine collection?
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Which complementary therapy is contraindicated for a client with herpes zoster?
Which complementary therapy is contraindicated for a client with herpes zoster?
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Match the steps for transferring a client with right-sided weakness to a chair:
Match the steps for transferring a client with right-sided weakness to a chair:
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When administering an opioid medication from a vial, who should witness the wastage?
When administering an opioid medication from a vial, who should witness the wastage?
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At what rate should the nurse set the pump for a heparin infusion?
At what rate should the nurse set the pump for a heparin infusion?
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Which step should a nurse remember when mixing regular and NPH insulin?
Which step should a nurse remember when mixing regular and NPH insulin?
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What should the nurse prioritize when a client refuses to use an incentive spirometer?
What should the nurse prioritize when a client refuses to use an incentive spirometer?
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Which component of a medication prescription should the nurse question?
Which component of a medication prescription should the nurse question?
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What action should the nurse take to prevent skin breakdown in a client with limited mobility?
What action should the nurse take to prevent skin breakdown in a client with limited mobility?
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How should the nurse transcribe a verbal prescription for levothyroxine?
How should the nurse transcribe a verbal prescription for levothyroxine?
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Which finding indicates infiltration at an IV site?
Which finding indicates infiltration at an IV site?
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What action should the nurse take when administering multiple medications via an enteral feeding tube?
What action should the nurse take when administering multiple medications via an enteral feeding tube?
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Which teaching strategy should the nurse use with an older adult client?
Which teaching strategy should the nurse use with an older adult client?
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Which action indicates the correct use of a cane by a client?
Which action indicates the correct use of a cane by a client?
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Which food item should be removed from a mechanical soft diet breakfast?
Which food item should be removed from a mechanical soft diet breakfast?
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What is the purpose of advance directives?
What is the purpose of advance directives?
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Which finding should indicate a nurse that a client has developed thrombophlebitis?
Which finding should indicate a nurse that a client has developed thrombophlebitis?
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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.
