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‣ the nurse receives report, reviews the electronic health record, and documents care in the nursing progress notes. Labs drawn and diagnostics completed per provider orders. education provided as appropriate. a client who is positive for human immunodeficiency virus (HIV) is admitted to a surgical unit after an orthopedic procedure. select the 2 possible routes of HIV transmission. a. feces b. blood c. semen d. urine e. sweat f. tears - ✓✓ANSWER: b, c HIV, which is the virus that causes AIDS is transmitted through infected blood, semen, and bloody bodily fluids. HIV is not spread causally. although HIV may be found in other bodily secretions, including feces, urine, sweat, tears, saliva, soutum, and emesis, the amount of virus is likely not sufficient enough to be transmitted. ‣ the nurse reviews the electronic health record and documents care in the nursing progress notes. medication administered and labs drawn per provider orders. which finding would the nurse identify as normal for a newborn? select all that apply. one, some, or all may be correct. a. flat abdomen b. corner of the mouth drops with crying c. baby's weight is 6lbs (2700g) d. copious watery discharge from eyes e. hands and feet appear cyanosed f. head circumference of 33cm (13 inches) g. does not blink in the presence of light h. nipples spaced widely apart. - ✓✓ANSWER: c, e, f The average newborn weighs between 6 and 9 pounds (2700 and 4000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13-14 inches). Newborns generally have protuberant (not flat) abdomens. The corner of the mouth dropping with crying is a sign of facial nerve paralysis that may have been caused during birth. Copious watery discharge which progresses to purulent is a sign of Chlamydia conjunctivitis and must be treated immediately. Newborns exhibit a blinking reflex when light is directed toward the eye. Widely spaced nipples, along with lymphedema and excessive nuchal tissue, are signs of Turner syndrome.
‣ the nurse reviews the electronic health record and documents care in the nursing progress notes. care and interventions completed per protocol. which intervention would the nurse perform while caring for an actively dying client? select all that apply. one, some, or all responses may be correct. a. admit the client in hospice care b. ensure the nurse talks to and not about the client c. perform aggressive laboratory tests d. provide client and family reassurance e. keep the client undisturbed for a long time f. try to set a comfortable environment in the room g. perform symptom management for the client h. encourage family to talk to the client - ✓✓ANSWER: b, d, f, g, h during the dying process both healthcare staff and visitors should talk to and not about the client. the nurse would provide comfort care by reassuring the client and family to reduce their emotional anxiety. a comfortable environment such as low lighting and soft music may assist with meeting emotional needs. the nurse would perform symptom management to improve the client's quality of life. the family should be encouraged to hold conversations with and talk to the client. the client should not be admitted into hospice care if he or she is actively dying. a client is admitted to hospice care if death is expected within 6 months. the clients should be repositioned as needed for comfort, rather than leaving the client undisturbed for a long period of time. ‣ the nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. labs drawn and imaging completed per provider orders. which finding noted during assessment would lead the nurse to determine that a client is at an increased risk for infection? select all that apply. one, some, or all may be correct. a. surgical incision b. inactive lifestyle c. urinary catheter d. poor diet e. intravenous access f. antibiotic therapy g. diminished appetite h. vegetarian diet - ✓✓ANSWER: a, c, e, f findings that increase the risk of infection in a client would be the presence of a surgical incision, a urinary catheter, and intravenous access. these are all portals of entry for microorganisms. antibiotic therapy can lead to a superinfection that eliminates the normal flora. inactive lifestyle, poor diet, and diminished appetite can all negatively affect the general health of a client but would not increase the risk of infection. a vegetarian diet is not known to increase the risk of infection, but some research shows it may reduce certain types of infections. ‣ the nurse reviews the electronic health records and documents visit-related care in the nursing progress notes. labs drawn per provider orders.
b. blood pressure of 135/80 mmHg c. oxygen saturation of 100% d. temporal temperature of 38. e. radial pulse rate of 72 and irregular f. pain of 6/10 with coughing. - ✓✓ANSWER: d, e, f the normal temperature is 36.0-38.0; temperature is often elevated with any type of infection. cardiac dysrhythmias are associated with a pulse deficit in which radial pulse would be irregular; reassessment would not be required. pleural pain associated with cough is expected with a pulmonary infection. in pulmonary infections, the respiratory rate would more likely be elevated than at the low end of normal. in fluid volume deficit, the blood pressure may be decreased. if oxygen saturation was changed with this client, it would be decreased, whereas 100% is at the high end or normal. a respiratory rate of 12 breaths/minute, a blood pressure of 135/80 mmHg, and an oxygen saturation of 100% would not be considered physiologic changes expected with this client. ‣ the nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? select all that apply. one, some, or all may be correct. a. dyspnea b. increased appetite c. flushed face d. precordial pain e. increased pulse rate f. increased blood pressure g. general lethargy h. chills - ✓✓ANSWER: c, e, f, g, h increased body heat dilates blood vessels, causing a flushed face. the pulse rate increases to meet increased tissue demands for oxygen in the febrile state. the client with a fever may demonstrate general lethargy or report chills. fever may not cause difficulty breathing. appetite will be decreased, not increased in the presence of a fever. precordial pain is not related to fever. blood pressure is not expected to increase with a fever ‣ a 50 year old client is diagnosed with chronic obstructive pulmonary disease (COPD). the clinical date on admission are as follows: a heart rate of 86 bpm, a BP of 142/ 82 mmHg, RR of 32 breaths/min, a tympanic temperature of 36.8, SpO2 88%, and general discomfort with a pain 2/10. which vital signs obtained by the nurse indicate an improvement in condition? select the 3 findings that indicate client improvement. a. radial pulse: 88bpm b. temperature: 37. c. respiratory rate: 14 breaths/min d. blood pressure: 110/70 mmHg e. oxygen saturation: 92% f. pain of 2/10 - ✓✓ANSWER: c, d, e The respiratory rate in older adults ranges from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus, a rate decrease to 14 breaths/min indicates a positive outcome, as it is within normal
range. COPD may also cause high blood pressure. Thus, a blood pressure of 110/ mm Hg obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95% to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse is slightly elevated but relatively unchanged, which does not demonstrate an improvement in condition. A body temperature reading of 98.6°F (37°C), is considered normal and not a sign of COPD. A pain score of 2 out of 10 does not indicate a positive or negative outcome and is not a sign of COPD. ‣ the nurse notes that the victim of an automobile crash may need cardiopulmonary resuscitation (CPR). which factor would the nurse remember about performing CPR? select all that apply. one, some, or all responses may be correct. a. emergency treatment that is provided without a clients consent b. not performed on adult clients who have already consented to a DNR order either verbally or in writing c. not to be performed by a primary health care provider in violation of a DNR order under any circumstances d. initiated immediately if cardiac rates drop below establishes normal rates for the clients gender and age. e. performed on appropriate clients unless a DNR order has been signed and made part of the clients record. f. can be initiated and performed in the healthcare setting by personnel who hold a basic life support (BLS) certification. g. generally performed on any client who requires resuscitation in an emerge - ✓✓ANSWER: a, b, e, f CPR is an emergency treatment provided to clients without formal consent. CPR would not be performed on an adult client who has already consented to a DNR order, either verbally or in writing. CPR is performed on appropriate clients unless a DNR order has been placed in the clients record. Personnel within a healthcare setting, no matter the role, are authorized to initiate and perform CPR if they hold a BLS certification. The primary health care provider is required to review clients' DNR orders in case there is a need for change because of the client's condition. CPR should be performed on those who do not have a palpable pulse or an absent heart rhythm, but not if heart rates are lower than established normal rates for the clients' gender and age. CPR is used in emergent situations to save lives in which the patient is unable to give consent, therefore consent is not necessary for the implementation of these rescue measures. CPR does not require an order from a primary healthcare provider, or someone trained in ALS, but is initiated upon meeting established criteria such as an absent heart rhythm or pulse. ‣ the nurse caring for a client postoperatively takes necessary steps to achieve quality client care. which nursing action satisfies the quality and safety education for nurses (QSEN) competency called informatics? select all that apply. one, some, or all may be correct. a. washing the hands before handling the clients incision site b. responding to generate alerts that cue necessary treatment procedures.
‣ the nurse is preparing to insert an intravenous (IV) catheter in a client who appears thin and emaciated and is scheduled to begin intravenous fluid therapy. which interventions would the nurse follow to provide high-quality care? select all that apply. one, some, or all may be correct. a. insert an 18-gsuge IV catheter b. change the IV line every 7 days c. flush the IV line with normal saline d. advance the needle 1/2 inch following flashback e. insert the IV catheter into the clients femoral vein f. stop the insertion procedure when there is a break in technique g. apply a tourniquet a few inches above the selected site i. after insertion assess for leaking and swelling. - ✓✓ANSWER: C, F, G, I the nurse would flush the IV line with normal saline to maintain patency. the nurse would stop the insertion procedure when there is a break in technique. this intervention helps prevent catheter-related bloodstream infections and provides high-quality care to the client. a tourniquet should be placed 2-3 inches above the planned insertion site. following insertion, the nurse should assess the site for leaking and swelling during administration of IV fluids. An 18-gauge needle is not an appropriate size needle to insert in a thin, emaciated client; it would cause unnecessary trauma and present a high risk of phlebitis. The nurse would change the IV line every 72 to 96 hours to prevent the risk of infection. The needle and catheter should only be advanced an additional 1/16th to 1/8th of an inch after flashback to ensure the catheter is in the vein. Advancing ½ an inch may result in going through the vein with the needle. The nurse would avoid inserting the catheter in the client's femoral vein because it increases the risk of bloodborne infections. Next ‣ the nurse is caring for a client who is terminally ill with cancer. the health care team meets and agrees to provide the client with information to help the client make decisions regarding treatment. which ethical principle is applied in this situation? select all that apply. one, some, or all may be correct. a. veracity b. nonmaleficence c. autonomy d. justice e. paternalism f. fidelity g. beneficence i. futility - ✓✓ANSWER: A, C, D, F the nurse follows the principle of veracity by telling the truth to the client regarding their health status. telling the truth helps the client in decision-making, which is in accordance with the principle of autonomy or self-determination and self-management. justice is an ethical principle that involves treating a client fairly without discrimination. fidelity involves being loyal to the client.
Nonmaleficence is the obligation to do no harm, this principle does not apply because the team is not providing any care or making any health care decisions at this point. Paternalism references a decision that is made by the healthcare provider when they think they know what is best for the client, this is in contradiction to the principle of autonomy and should not be used in this scenario. Beneficence involves acting in a way that causes the least harm to the client, like maleficence this principle does not apply since the team is not providing care at this point. Futility involves decisions regarding treatments that the healthcare provider believes will not provide a benefit to the client, it also does not apply since no treatments are being provided. ‣ parenteral vitamins are prescribed for the client with crohn's disease. the client asks why the vitamins have to be given intravenously (IV) rather than by mouth. which rationales will the nurse provide? select the 4 findings that offer the correct rationale. a. "they provide more rapid action results." b. "they decrease colon irritability." c. "oral vitamins are less effective." d. "intestinal absorption may be inadequate." e. "allergic responses are less likely to occur." f. "it doesn't rely on liver absorption." - ✓✓ANSWER: A, C, D, F absorption through the GI tract is impaired, and parenteral administration goes directly into the intravascular compartment resulting in more rapid results. oral vitamins are less effective in general because of the resilience on proper absorption and processing. because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired. when vitamins are given parenterally, they bypass the entire GI system, including the liver. IV vitamins don't decrease colonic irritability associated with crohn's disease. the route of administration does not affect allergic response. ‣ the nurses advocate role for a victim of intimate partner violence (IPV) would include which important component? select all that apply. one, some, or all may be correct. a. planning for future safety b. normalizing victimization c. ordering tests for sexual diseases d. validating the experience e. promoting access to community resources f. providing housing for the victim. g. administering medications for comfort i. reporting findings to community health. - ✓✓ANSWER: A, D, E the nurse would include planning for future safety, validating experiences, and promoting access to community resources. Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse. Ordering tests for sexually transmitted diseases is not within the scope of practice for a nurse. The advocate role would include information and resources for housing if
response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Hyperthyroidism is also associated with common signs and symptoms, such as hot flashes and shaking hands. ‣ which information would the nurse provide to the client about the benefits of rehabilitation? select all that apply. one, some, or all may be correct. a. "specialized rehabilitation services help clients and caregivers to adjust to lifestyle changes." b. "insurance includes all types of rehabilitation as a covered benefit." c. "rehabilitation helps prevent complications associated with illness or injury at the initial stages." d. "clients who receive rehabilitation attain their fullest physical, mental, social, vocational, and economic potential." e. "programs are used solely to help clients become free from chemical dependency." f. "services focus on maximizing a client's functioning and level of independence at the initial stages. " g. "these services enable clients to function with the limitations of their illness." i. "most of these healthcare services take place within specialized hospital facilities." - ✓✓ANSWER: A, C, D, G Specialized rehabilitation services, such as cardiovascular, neurological, musculoskeletal, pulmonary, and mental health rehabilitation programs, enable clients and their caregivers to adjust to lifestyle changes. At the initial stages, rehabilitation aims to prevent complications associated with the illness or injury. Rehabilitation enables clients to reach their highest physical, mental, social, vocational, and economic potential possible. Rehabilitation services assist the client to function within the limitations of their illness. Insurance may limit coverage for certain types of rehabilitation, either fully, partially, or not covering the service at all. Drug rehabilitation is only one type of rehabilitation program. Clients may require rehabilitation after a physical or mental illness, injury, or chemical addiction. When the client's condition stabilizes, rehabilitation helps maximize his or her functioning and level of independence. Rehabilitation often takes place in the community setting at conveniently located facilities for the client and is not limited to specialty hospitals.
