Kaplan Fundamentals A&B PDF

lOMoARcPSD|44672366 Kaplan Fundamentals A&B Directed Studies In Nursing (Variable) (Rose State College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university...

lOMoARcPSD|44672366 Kaplan Fundamentals A&B Directed Studies In Nursing (Variable) (Rose State College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 1 1 of 49 I do not have specific details on Kaplan but here are some areas to be familiar and to review: Ways to prevent circulation and respiratory complications in patients. 1. The MOST important assessment to perform after a cardiac catheterization is to check for peripheral pulses 2. The MOST important factor to maintain adequate circulation is blood volume 3. Peripheral arterial disease a. Red feet, cool, shiny smooth hairless skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, decreased peripheral pulses, bruit or thrill over site of occlusion, pallor with elevation b. Monitor peripheral pulses, lower legs, good foot care, teach not to cross legs, encourage regular exercise, stop smoking, vasodilators/ anticoagulants/antiplatelets 4. Peripheral venous disease (PVD) a. Cool, brown skin, edema, ulcers, pain, normal or decreased pulses b. Monitor peripheral pulses, elevate legs, apply compression, apply warm moist packs, anticoagulants, bedrest 4-7 days, avoid extremes of temperatures 5. Signs of HF include tachycardia, increased resp rate, ShOB, chest congestion, orthopnea, fatigue, edema, nocturia, skin changes, behavioral changes, chest pain, weight changes 6. VTE- pain in affected limb, localized edema of one extremity, warm skin over affected area, possible fever/chills/perspiration; notify HCP immediately if chest pain or ShOB 7. Pursed-lip breathing prevents trapping of air Aseptic practices: preventing infections a. Standard precautions: apply to all patients; blood, body fluids, secretions  Wash hands immediately on contact w/ blood or body fluids i. Hand hygiene when gloves are removed ii. Hand hygiene between patient contacts iii. Hand hygiene between procedures or tasks w/ same patient iv. Wear gloves when touching blood or body fluids v. Don gloves before touching mucous membranes or non-intact skin vi. Wear mask, face shield, gown if splashes or sprays likely vii. Appropriate handling and disposal of needles a. Contact precautions: private room or shared room w/ another patient w/ same infection, clean gloves, change gloves after contact w/ fecal material or wound drainage, wear gown if clothing will have contact w/ patient or environment or if client has diarrhea/ileostomy/colostomy/wound drainage; MRSA, VRE, Blood, mucous, or skin infections = contact precautions Requires gloves, gown b. Droplet precautions: wear surgical mask patients also have to wear one), gloves, and gown...pathogens transmitted by infectious droplets (c-diff, streptococcal pharyngitis, pneumonia, meningitis caused by H. influenza type B, mumps, pertussis, pneumonia), contact with conjunctiva or mucous membranes or nose/mouth; private room or cohort, Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 2 2 of 49 maintain 3 feet between patient and visitors/other patients, mask on client if being transported c. Airborne precautions: private room w/ negative air pressure & air changes 6-12 per hour, keep door closed, can cohort w/ patient w/ same organism, mask on patient if being transported, all personnel wear fitted N95 respirator; measles, TB, varicella (chicken pox, zoster, shingles (disseminated zoster) d. Medical asepsis- clean technique e. Surgical asepsis- sterile technique; know principles Dressing changes Assessment: pulses/BP/respirations/temperature a. Adult vital signs: HR 60-100 bpm, Resp 12-20 breaths/min, Oral temp 98.6 (37), BP Samples taken in beginning/not needed routinely, assess for inflammation not perfusion 9. The nurse provides care for a client with an abdominal wound. The nurse notes there is purulent drainage from the wound. Which action does the nurse take first? a. Places the client on contact precautions Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 12 12 of 49 10. The nurse provides care for a client at risk for developing a pressure injury. The nurse knows which factor puts the client at risk? (Select all that apply) a. bony prominences b. immobility c. low serum albumin 11. Moist to dry dressing changes are prescribed for a client. After the first layer of dressing as removed, the client yelled at the nurse, “ouch, that really hurts. Are you sure you’re doing it right?” Which statement is the best response by the nurse? a. I’m sorry this hurts, I will add some normal saline to loosen it a bit more 5. The nurse identifies which diet best meets the needs of a client with multiple wounds? 1. High vitamin C, high-protein, high carbohydrate diet Rationale: Increasing vitamin C = central to wound healing. Increasing Protein = tissue growth Increasing Carbohydrate= is critical so the body can generate enough energy that the protein is properly utilized for tissue Repair. 6. An older adult client has red area on the coccyx. Which action does the nurse take first? 1. Reposition the client every 1 to 2 hours Rationale: Incorrect answers Continuous assessment of the area - this situation does not require further assessment any reddened area requires an intervention to prevent a pressure injury Massage the reddened area four times per day- do not massage red areas. Massages causes damage to capillaries in deep tissue and promotes a pressure injury. Places the client in a semi- reclining position = This position causes shearing forces on a sacral area. Shearing occurs when the client is pulled or allowed to slump in the bed. 7. A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique? 1. I should wash my hands before re-dressing my wound Rationale: this indicates understanding of asepsis – hallmark is handwashing Incorrect answers I need to buy sterile gloves to redress this wound. - Not most important I should keep the wound covered at all times - is not possible to carry out I should use an over-the-counter anti-microbial ointment- use only the prescribed medications on the wound NUTRITION/EXERCISE 12. The nurse knows that serum albumin is used as an indicator of malnutrition for which reason? a. Serum albumin is easy to measure, and can indicate a protein deficiency that may not be detected on physical examination i. 3.4-5.4 normal range 13. At discharge, the nurse advises a client about a calorie-restricted diet. Which is an ideal rate of weight loss? a. 1 pound per week Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 13 13 of 49 14. The nurse provides care for a client with a body mass index BMI of 17.0 KG/M.which is the best description of the client’s body weight? a. Underweight 8. The nurse provides care for a client with a body mass index (BMI) 38 kg/M2. Which is the best description of the client’s body weight? 1. Obese Rationale: BMI less than 5, muscle cramps, weakness, bradycardia, ventricular fibrillation iv. Hypocalcemia/ hypomagnesemia = Tetany v. Rusty or dirty metal puncture = causes tetanus 79. The nurse provides care for a client receiving a blood transfusion. The nurse is most concerned if which observation is made? 1. Hematuria occurs 80. The nurse identifies which S/S indicates a client may have fluid volume excess? (Select all that apply) 1. Edema 2. Tachycardia 3. Crackles Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 31 31 of 49 81. The nurse observes a student nurse begin an IV on an older adult client. The nurse intervenes if which action is observed? 1. The student uses vigorous friction and tapping of the vein as a dilation method 82. The nurse notices an IV infusion is not running. Which action des the nurse take initially? 1. Assess the site 83. The nurse monitors a client receiving a blood transfusion. The nurse should intervene if which is observed? (Select All that Apply) 1. The blood infuses at 10mL/min for the first 15min 2. The client reports Dyspnea 3. The client reports Peritus i. S/S of circulatory overload = Dyspnea, cough, rales, JVD ii. Immediate = Position Fowlers w/feet dependent iii. Initiate = Diuretics, Oxygen, Aminophylline 84. Client sustains burn injury, area is blistered & painful. What classification best describes the burn area? 1. Deep partial thickness 85. The nurse provides care for a client who experiences a transfusion reaction. Which is the nurse’s first action? 1. Stop the transfusion 86. The nurse determines a client has a deep partial thickness injury of the back. Which is the best initial nursing action? 1. Gently clean the area and determine the extent of the burn 87. The nurse assesses a client receiving a blood transfusion. The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction? 1. Kidney pain, hematuria, cyanosis 88. The nurse provides care for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs during the transfusion? 1. ↑Pulse rate, ↑BP, ↑ respirations 89. When measuring the central venous pressure, it is most important for the nurse to take which action? 1. Place the manometer at level of the right atrium 90. A client suffers a full thickness burn injury, during the emergent phase, the nurse expects = ↓ urine output, ↓ cardiac output, ↓ kidney perfusion, urine will have high specific gravity 1. CVP fluid overload 15mm Hg = normal (2-8) 91. The nurse instructs a client with full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which foods on the breakfast menu? 1. Scrambled eggs with cheese, sausage, and orange (needs Vitamin C, protein, & calories when burned) 92. Client with persistent vomiting and abdominal pain. Nasogastric tube is inserted and connected to suction. IV infusion with 20mEq of potassium chloride is started. Why was potassium added? 1. Replaces the potassium lost in the gastric fluid 93. The nurse knows which client is most likely to manifest symptoms of fluid volume deficit? 1. The client diagnosed with Addison disease i. Symptoms fatigue, weakness, dehydration, weight loss, F&E imbalance, & hypotension ii. Reduced aldosterone secretion = ↑Na & water secretion, volume depletion iii. Cirrhosis of the liver & SIADH= fluid volume overload 94. Client with diabetes insipidus, which imbalance is most likely to develop if medical problem recurs? 1. Hypernatremia i. S/S excessive urine output, chronic/severe dehydration, excessive thirst, weakness, ii. Monitor = I&O, specific urine gravity, condition of skin, vitals, admin-desmopressin 95. Preeclampsia receives Mg sulfate IV as treatment, most important intervention 1. Reflex hammer & Calcium gluconate i. Hamer checks Deep tendon reflex, Ca blocks cardiac effects of ↑mg 96. Hypokalemia imbalance if Nasogastric drainage, Vomiting, Diarrhea, diuretics 97. Which lab findings does the nurse expect if a client is diagnosed with a fluid volume deficit? (select all that apply) Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 32 32 of 49 1. BUN 32 mg/ 100mL 2. Potassium 5.8 mEq/L 3. Specific Gravity 1.034 98. Central line inserted in a client, the client reports dyspnea, SOB, & chest pain. The likely cause of symptoms is which condition? 1. Pneumothorax (collapse of the lungs) 99. RBC transfusion, needs another unit, which action is most appropriate to take for the nurse initially? 1. Check the type and cross-match with another nurse i. Blood match, medications, & expirations need to be double checked (also abnormal vitals) 100. The nurse evaluates client’s fluid balance. Which finding most likely requires an intervention? 1. Output is 800mL less than intake i. I&O should be 200-300mL of each other ii. Normal intake 1500-3000mL/ day 101. Thermal burn injury client, the nurse is most concerned if which observation is made? 1. The client has singed nasal hairs (due to inhalation, respiratory) Arterial Blood Gas 102. Which action is essential for the nurse to take after ABGs are drawn? 1. Apply pressure to puncture site. Rationale: ABGs measure acid/base balance. Blood sample typically drawn from radial artery. Apply pressure for five full minutes to prevent bleeding or hematoma. 103. Over which anatomically area on the chest wall does the nurse place the stethoscope to most clearly auscultation the apical pulse? 1. Mitral area 104. The nurse identifies that which set of vital signs is within the normal range for an adult? 1. BP 120/70, Pulse 68, RR 16 105. Which pulse site is located below the i Guiana ligament and is frequently used to assess a client’s pulse during cardiac arrest? 1. Femoral pulse 106. The nurse instructs a client on the procedure to palpate and count the pulse. Which client action indicates the nurse further instruction is needed? 1. The client places a thumb over the pulse point. 107. To access the pedal pulse, the nurse palpated in which location? 1. The top of the foot. 108. Which is the correct way to accurately assess the client’s radial pulse? 1. Locate the pulse on the inner aspect of the wrist, county the beats for 30 seconds, and multiply by two. 109. The nurse takes the apical pulse of a client receiving digoxin. Which nursing procedure is correct? 1. The nurse places a stethoscope over the point of maximal impulse and counts the number of heartbeats for one full minute. Rationale: The apical pulse is obtained by placing a stethoscope over the PMI and counting all heartbeats for one minute. Normal pH = 4.5 – 8 b. pH is affected by Diet, Medications, Infections, Acid-Base Balances, & altered Kidney functions Specific Gravity Urine Tests = Normal = 1.010 – 1.030, clear & yellow c. Lower than 1.010 = Kidney damages d. Higher than 1.030 = Hyperglycemia or Proteinuria e. Cloudy = Infection Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 33 33 of 49 f. Darker colors – could indicate blood g. Urine Output = 50-60mL /hr (1500mL / day) Patient Positioning: 1. High Fowlers = GI tube, Ease of Breathing, coughing 2. Semi Fowlers = Vitals, NP Suctioning, 3. Sims = Rectum (jackknife) / Vagina assessments 4. Side Lateral = (L) Suppository/Enema placement, 5. Supine = Abdomen assessment (sometimes with knees flexed {w/pillow 4 comfort}) 6. Prone = Back assessments, backside surgeries 7. Lithotomy = Feet in stirrups Tactile Fremitus (palpable vibration) = use ulnar & palmar surface of hand to feel when patient talks in chest area HEALTH Assessment: ADPIE = Assess, Diagnose, Plan, Inspect, Evaluate Inspect, Auscultation, Percussion, Palpation 2. Physical Exam = Inspect, Palp, Perc, Ausc BP=120/80 Temp = Pulse = 60-100 b/m Pulse Ox = measures the amount of oxygen circulating in your blood RR = 12-20 Capillary refill = 1-3 seconds 2. Which method does the nurse use to test a client’s gag reflex? 1. Touch the back of the throat with a cotton-tipped applicator 3. Correct procedure for the nurse to use to examine a client’s pupil? 1. Compare the size of both pupils and check the reaction to light 4. The nurse in the outpatient clinic receives a phone call from a client reporting a rash. Which actin does the nurse take first? 1. Determine if the client is taking any new medications 5. Neurological assessment, tap right leg for patellar reflex with no movement, which action does the nurse take first? 1. Tap the tendon again while the client is pulling against interlaced, locked fingers 6. Which assessment finding in a young adult indicates to the nurse that there is a problem with fluid volume deficit? Tenting of the skin 7. Client with Cheyne-Stokes respirations, breathing pattern expected? 1. Gradual ↑ in depth of respiration, followed by a gradual ↓ in depth, then a period of apnea 8. The nurse prepares to assess a client’s ears & hearing. The nurse gathers which piece of equipment? (Select all) 1. A tuning fork 2. An Otoscope i. Rationale = 1. Tonometer – measures intraocular pressure 2. Percussion Hammer – deep tendon & superficial reflexes 3. Stethoscope – clients body to nurses ear 9. Which risk factor does he nurse MOST likely contribute to an elevation of a client’s blood pressure? 1. A high- pressure job (hypertension) Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 34 34 of 49 10. Friction rub = Grating sound & vibration heard during inspiration & expiration 11. After completing the data collection process of a client’s health history interview, which actin does the nurse take first? 1. Summarize the highlights of the interview & permit the client t add or clarify info 12. Auscultate a clients breath sounds, vesicular sounds have which characteristics? 1. Soft & low-pitched breezy sounds heard over most of the peripheral lung fields 13. Visual acuity Snellen chart reported 20/60, 60 indicates? 1. The distance at which the client with normal vision can read the chart 14. Increased pulse pressure, education to the client = the difference between systolic & diastolic blood pressure readings 15. Apical pulse = 5th intercostal space & left midclavicular line Nutrition 1. Prescribed low sodium diet a. Select fresh, low sodium foods & ask that no salt be added during cooking 2. Increase fat soluble vitamins in the diet, nurse would teach? a. Eat more eggs, whole milk, & salmon to ↑ vitamin D i. Egg yolk, milk w/butterfat, salmon, & cod liver ↑ in Vit-D, some fortified OJ too ii. Vit-A = Green leafy & yellow veggies, pineapples iii. Vit-B = whole grains iv. Vit-C = Fresh squeezed OJ, v. Vit-E = Soybean, corn, wheat germ vi. Vit-K = Oats, wheat, rye, Oranges, apricots, cantaloupe, raisins, and dates, peas, potatoes, beans, avocado, asparagus, spinach fish, lamb, clam, yogurt vii. Calcium = Sardines, Almonds, Cheese, Fortified OJ, Yogurt 3. The nurse teaches a client which principle about water soluble vitamins? a. Must be taken every day (does not store in the body, quickly removed) 4. Client with kidney disease, does not need dialysis, nurse teaches which dietary considerations? a. Most calories should come from carbohydrates & fats i. Na/K limited but Proteins/fluids restricted, since kidneys do not filter well. 5. Crohn disease, client loses weight & has diarrhea, what additional finding does the nurse expect related to malabsorption? a. Paresthesia, = caused by vitamin deficiency b. Steatorrhea, = Stool is fatty, greasy, foul smelling due to malabsorption c. Muscle Wasting, = no/low protein causes d. Anemia = no/low iron absorption e. Tachycardia & Hypotension = due to dehydration f. Low residue/fiber diet = White rice, poached fish, bran, lean meats 6. Hindu avoid which foods? a. Meats & poultry (any meat, is taking a life) 7. Strict Jew, which items would the client refuse to eat? a. Hamburger with bun, mashed potatoes, green beans, butterscotch pudding i. Meat & Milk products are NOT consumed at the same meal ii. Mashed potatoes usually have milk, pudding is milk product 8. Clear liquid diet progressed to full liquid diet, which items can the client add to the menu? a. Coffee with cream & sugar b. Tomato soup, strained c. Ice cream, plain yogurt, pudding, custards Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 35 35 of 49 d. Cream of rice cereal e. Fruit juice w/o pulp (NO applesauce) 9. Mormonism will refuse which beverages? a. Wine (no alcohol) b. Coffee (no caffeine) 10. Celiac Disease, which foods? a. Corn tortillas with ground beef, sauteed onions & peppers, sour cream, & guacamole i. No gluten meals 11. Nutrition is correct? a. Basic nutritional components are carbohydrates, fats, & proteins b. Proteins are made up of nitrogen containing amino acids 12. High fiber diet to treat constipation, which are correct menu items? a. Navy bean soup, cornbread, peas, and raspberries 13. Assess a Clients nutritional status, which method provides the BEST assessment? a. Have the client complete a diet diary i. Ask about food like & dislikes = cause of imbalance 14. Low cholesterol diet, best understanding of the diet? a. I can keep my cholesterol intake low if I eat foods that have no animal protein 15. Peptic Ulcer = Avoid alcohol or food that cause distress (no special diet) 16. Low fat, low sodium diet, which statements contain correct info? a. Processed lunchmeat contains fat & sodium b. Limit the amount of lean meats and remove visible fat c. You can have all the raw vegetables you want 17. Client on furosemide, besides bananas what else can I eat to get potassium? a. Oranges, apricots, cantaloupe, raisins, and dates 18. Difficulty chewing following a stroke, what diet does the nurse request? a. Mechanical soft 19. Burn victim = High level of proteins, carbs, with moderate amounts of fat are needed 20. Client with Inflammatory bowel disease, lost weight and is malnourished, which action is most helpful for the client? a. Help client use a food diary 21. Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 36 36 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 37 37 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 38 38 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 39 39 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 40 40 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 41 41 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 42 42 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 43 43 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 44 44 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 45 45 of 49 Hyperventilation ay be observed – using Assist-Control Ventilation (AC) o AC = O2 admin w/o effort o CPAP = Sleep Apnea o Controlled Mechanical Vent (CMV) = for those that cannot breathe independently (set rate set)/ keeps them alive  Guillain -Barre Syndrome  Required/ Essential = Resuscitation Bag o Synchronous Intermittent Mandatory Vent (SIMV) = Synchronized with client’s inspirations Oxygen Face Mask = Most Concerning if they have a nonproductive cough (to much O2) Thoracentesis causes Subcutaneous Emphysema (swelling in right side chest & neck) Surgery complication causing crackles in lower lobes = Atelectasis Postural Drainage used for Cystic Fibrosis Car accident caused Tension Pneumothorax – needs Chest Tube Insertion Opioids (Hydrocodone) – no for Asthma or breathing issues Chronic Bronchitis = Take 3 or 4 breaths, and as you exhale the last breath, cough 3x Choking = 1) Ask them a question, can they breath, Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 46 46 of 49 2) goes Cyanotic = Stand behind the client, wraps arms around the clients waist, and with a fist makes a quick upward thrust into the abd 3) Abd thrust – dislodges food or other foreign bodies from the Airway Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 47 47 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 48 48 of 49 Downloaded by Dai Yin Lin ([email protected])  lOMoARcPSD|44672366 49 49 of 49 Downloaded by Dai Yin Lin ([email protected])