RN Fundamentals 2016 A

C. "You should have a fecal occult blood test every year." Blood tests do not detect colorectal cancer. Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. Another option for screening is a flexible sigmoidoscopy every 5 years.

D. Assist the client to an upright position The nurse should use less invasive interventions first.

A. Gently shake the container of medication prior to administration Pt. should be in the high-Fowler's position when administering medication. The nurse should NOT transfer prepackaged liquid medications to reduce the risk of altering the premeasured dose.

D. Use a clock pattern to describe food on the client's plate Large-handle adaptive utensils are easier for the client to grip. Clients who have, dysphagia, NOT vision loss, require thickening of liquid to facilitate swallowing without choking.

A. Walking briskly Exercise with no weight-bearing advantages, like B and C, do not help prevent osteoporosis. High-impact aerobics can injure bones that have lost density.

A. "I can concentrate best in the morning."

C. "I'll check the wires and cables on my TV to make sure they are in good working order. Oxygen is a highly flammable gas. The visitors should smoke outside the house. Woolen and synthetic materials can create sparks, so the client should use a cotton blanket during O2 therapy.

C. Use progressive relaxation techniques at bedtime Cocoa contains caffeine, a stimulant, and can interfere with sleep. Exercising within 2 hr of bedtime can interfere with sleep. Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension. Reflecting can cause stress and worry, which can interfere with sleep.

C. Semi-Fowler's Trendelenburg is the position of the pt's head being below their feet; this position does NOT promote full expansion of the lungs.

A. Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measure to protect the skin from further breakdown A pt should drink 2,500 to 3,000 mL of fluid per day Bowel movement less frequent than three per week indicate constipation and the need for intervention

C. "I flushed what I urinated at 7:00 a.m. and have save all urine since." The pt should collect urine that is free of feces. The pt should place any urine in the container immediately and keep it on ice or in a refrigerator. The client should discard the first voiding and save all subsequent voidings. There is not specified amount needed for a 24-hour urine collection.

D. Acupuncture Acupuncture is contraindicated for a pt who has herpes zoster (aka shingles), or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk for further infection. Feverfew is contraindicated in pts who are prescribed warfarin or other blood thinners.

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

A. Ask another nurse to observe the medication wastage A second nurse must witness the disposal of any portion of a dose of a controlled substance Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance The nurse should not lock the remaining medication in the cabinet because this is a violation of the Controlled Substances Act The nurse should NOT dispose of the remaining medication in the sharps container because this is a violation of the Controlled Substances Act

8 mL/hr

1. Inject 10 units of air into the bottle of NPH insulin. CLOUDY. 2. Inject 5 units of air into the bottle of regular insulin. CLEAR. 3. Withdraw the correct dose of regular insulin from the bottle. CLEAR. 4. Withdraw the correct dose of NPH insulin from the bottle. CLOUDY. Cloudy insulin (NPH, Humulin N, Novolin N) should NOT enter clear insulin (regular, Humulin R, Novolin R) Inject air into cloudy, Inject air into clear, Draw up clear, Draw up cloudy ------ Inject 10 units of air into the bottle of NPH insulin. Inject 5 units of air into the bottle of regular insulin. Withdraw the correct dose of regular insulin from the bottle. Withdraw the correct dose of NPH insulin from the bottle. ------ The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

B. Determine the reasons why the client is refusing to use the incentive spirometer. Assess first

C. The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

D. Have the client use a trapeze bar when changing position By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

B. 0.3 mg

C. Skin blanching Skin blanching, edema, and coolness and the IV site indicate infiltration.

D. Flush the tube with 15 mL of sterile water When dissolving medications, the nurse should dissolve each medication in at least 30 mL of warm, sterile water The nurse should draw up medications separately and not mix them together If the nurse encounters resistance when administering medications, he should stop and contact the provider The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication

A. Allow extra time for the client to respond to questions Older adult clients often process information at a slower rate than younger clients The nurse SHOULD explore the client's past experiences and use them to establish connections to new knowledge It is helpful when working with older adult clients to invite another household member to the teaching session so that person can help reinforce new information later. The nurse, however, should honor the client's preference.

C. The client holds the cane on the stronger side of her body. The top of the cane should be parallel to the client's greater trochanter To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time The can should be held on the stronger side of the body to increase support and maintain alignment The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg

D. Fried egg Soft fruits, such as bananas or cooked fruits, are acceptable for a client who requires a mechanical soft diet Evidence-based practice indicates the nurse should remove the fried eggs from the client's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item

B. "They indicate the form of treatment the client is willing to accept in the event of serious illness."

C. Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

B. "The pain is like a dull ache in my stomach." A. describes the severity of the pain B. describes the quality of the the pain C. describes a factor that aggravates the pain

A. Press gently on the tragus of the client's ear If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward For an adult client, the nurse should move the auricle upward and backward OR upward and outward to straighten the ear canal The client should lie on her side with the ear that received the instillation facing upward for 2 to 5 minutes

D. "Are you able to help with your hygiene care?" The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, the nurse's priority is to assess the client's ability to assist with her hygiene care

D. Have family members wear a gown and gloves when visiting The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, it does not kill Clostridium difficile spores.

B. Pupil clarity D. Visual fields C. Visual acuity Cloudy pupils mean that the pt has cataracts, which can increase his risk for falls Visual fields are tested by the use of a finger test by moving it out of range and then back into his visual field to determine when he sees the finger Visual acuity should be assessed using a Snellen chart

D. Reassure the client that this is an expected response to grief During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis

B. Place the client's arm in a dependent position The nurse should insert the catheter at a 10 to 30 degree angle The nurse should place the pt's arm in a dependent position because the veins will dilate due to gravity The nurse should CLIP excess hair and AVOID shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection The nurse should AVOID using the fragile veins of an older adult's hands because the loss of subcutaneous tissue makes those veins roll away from the needle

D. Stand close to the cabinet when lifting This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching

D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further medical incidents

A. "Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

B. Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus The patient should be sitting in a high-Fowler's position with the head of the bed elevated to 90 degrees to reduce the risk for aspiration The nurse should withdraw the NG tube slightly, not remove it, when the client gags or chokes to reduce the risk of injury to the client Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea

D. Contact precautions Clients who have an immune-system compromise require a protective environment Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client

C. Cleanse the wound from the center outward The nurse should clean the wound from the center outward to prevent introduction of microorganisms from the outer skin surface

C. Remove the stockings at least once per shift The nurse should ensure there are no creases or wrinkles in the stockings to prevent skin irritation and promote venous return The nurse should apply the stockings in the morning before the client gets out of bed because the client's legs are less edematous at that time The nurse should remove the stocking once per shift to check the client's circulation and skin integrity The client should wear the stockings while sitting in the chair to promote venous return. He should also avoid crossing his legs

B. Tell the client to keep the head of the bed elevated at least 30 degrees All of the actions are appropriate; HOWEVER, the first action the nurse should take when using the ABC approach to pt care is to prevent aspiration of the enteral formula. This is done to prevent reflux of the formula backward into the esophagus

A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care E. Use antimicrobial sanitizer for hand hygiene The nurse does NOT need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and have him wear a surgical mask when he does leave the room. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions

A. Check the client for injuries

C. Role overload

A. Auscultate lung sounds All of the actions are appropriate; HOWEVER, the priority assessment the nurse should make when using the ABC approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. ----- The nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

A. Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries

C. Rapid heart rate Tachycardia indicated fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days Neck vein distension is a clinical manifestation of fluid-volume excess Typically, a client's urine specific gravity is greater than 1.030 in the presence of fluid-volume deficit Hypotension is an expected finding for a client who has fluid-volume deficit

A. "What could I have done to deserve this illness?"

C. Subtract the amount of irrigant used from the client's urine output For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter Open irrigation technique requires instilling 30 to 40 mL or irrigation fluid. The nurse should use a 30 to 50 mL syringe to perform open irrigation

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

D. Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report this finding. The client is at risk for dysrhythmias. Potassium: 3.5-5 mmol/L

A. Airborne Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles Contact precautions are needed for: VRE, MRSA, and scabies Droplet precautions are needed for: rubella, meningococcal pneumonia, mumps, and streptococcal pharyngitis

B. "This is a difficult time, but we are helping each other through this."

D. Initiate an enteral feeding through a gastrostomy tube Nurses can initiate enteral feedings through nasoenteric, gastronomy, and jejunostomy tubes All other activities require a physician or Advanced Practice Nurse (APN) to perform them

B. A nurse asks a nurse from another unit to assist with her documentation Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPPA guidelines

B. Select a suction catheter that is half the size of the lumen The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa the nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation to decrease trauma to the mucosa The nurse should adjust the suction pressure to approximately 120 mmHg and no higher than 150 mmHg to prevent hypoxemia and trauma to the mucosa.

C. Have the client stand with her arms at her side and her feet together Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance.

B. Situation, background, assessment, and recommendation (SBAR) A critical pathway is an interprofessional approach to planning all phases of client care. The nurse should use a transfer report when the client is moving from one health care area or facility to another The nurse should use the MAR to document medication administration