Airway management
Focused review
Airway management – considerations when reading oxygen level is less
than 90%, nurses should remain with the client and provide emotional
support to decrease anxiety. The expected range is 95% to 100%
Home safety- prevention is important because elderly clients can have
longer recovery times from injuries and the risk of complications. Place
grab bars near the toilet and in the tub or shower, and install a stool
risers. RICE Is for a sprain and RACE is for incase of a fire.
Adolescents- adolescents have a longer attention span. The CDC
recommends adolescents to have varicella, HPV, and seasonal influenza
Health promotion and disease prevention- determine risk factors first to
determine the client’s need for health promotion and disease prevention
What guidelines should the nurse follow when cleaning equipment from
the room of a client who is prescribed contact precautions?
Most facilities use disposable thermometer and BP cuffs and have a wall
clock for use, if not use a Ziploc bag before entering room.
Pens should be left in the room and clipboards should be kept outside of
the room.
Two hampers in the room should be used, one for linens and one for
garbage. At the end of the shift the bags should be emptied
A nurse is caring for an adolescent client and is reinforcing education
related to injury prevention. What information should be included?
Keep firearms in a locked cabinet
Teach proper use of sporting equipment prior to use
Insist on helmet us and pads when roller skating, skateboarding,
bicycling and during any other activities that increase injury risk
Avoid trampolines
Beware of changes in mood and monitor for self-harm
What is pulse oximetry and what is a normal finding? What could cause
an abnormal reading?
,Pulse oximetry is a noninvasive measurement of the oxygen saturation
of the blood for monitoring respiratory status
A normal finding is 95% to 100%
The cause of an abnormal reading is hypothermia, poor peripheral blood
flow, too much light, low hemoglobin levels, jaundice, movement,
edema, and nail polish
A nurse is caring for a client with a diabetic ulcer which is has a
bacterial infection. Identify the lab values the nurse will review to
monitor for infection.
Elevated WBC = the expected range is 5,000-10,00
Elevated ESR = expected range is 15 to 20mm/hr
A nurse in the treatment plan of a client with a stage III wound has an
order to irrigate the wound site. Identify nursing measures to safely
clean and irrigate the wound for this client
clean and/or debride the following, prescribed dressing
surgical intervention
proteolytic enzymes
provide nutritional supplements
administer analgesics
administer antimicrobials
To reduce the risk of Hepatitis A transmission identify three (3)
measures use to maintain standard precautions.
A private room or a room with other clients who have the same infection
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag
without touching the outside of the bag
The nurse receives an order to administer enteral tube feedings to a
client with dysphagia. The order states- Administer 1500 mLs of enteral
feeding over 18 hours via infusion pump. What will the mLs per hour
be? Round to the nearest whole number.
1500/15=83
, Name the two (2) preferred sites of an intramuscular injection in an adult
client. When is it recommended to use the larger muscle site?
Ventrogluteal and deltoid
It is recommended to use ventrogluteal site when deltoid is not used.
A nurse is checking the pulse oximetry of a hospitalized client who is on
2 liters of oxygen by nasal cannula. The finger probe is showing 89%
oxygen saturation. Which of the following may produce a low reading?
(Select all that apply).
Hypoxemia
Nail polish
Poor peripheral blood flow
Low hemoglobin
Describe three (3) special considerations when starting an IV on an older
adult client with fragile veins.
Avoid tourniquets
Use a blood pressure cuff instead
Do not slap the extremity to visualize veins
Avoid rigorous friction while cleaning the site
The nurse is caring for a client who has a would drainage device in
place. Discuss the use and benefits of this drainage system.
Promotes drainage of fluid from the incisional site
Decreases pressure on tissues
Decreases abscess formation
Promotes healing from inside out
Reduces bacterial counts through debridement
Promotes granulation
Stimulates cell growth
Focused review funds 2
Focused review
Airway management – considerations when reading oxygen level is less
than 90%, nurses should remain with the client and provide emotional
support to decrease anxiety. The expected range is 95% to 100%
Home safety- prevention is important because elderly clients can have
longer recovery times from injuries and the risk of complications. Place
grab bars near the toilet and in the tub or shower, and install a stool
risers. RICE Is for a sprain and RACE is for incase of a fire.
Adolescents- adolescents have a longer attention span. The CDC
recommends adolescents to have varicella, HPV, and seasonal influenza
Health promotion and disease prevention- determine risk factors first to
determine the client’s need for health promotion and disease prevention
What guidelines should the nurse follow when cleaning equipment from
the room of a client who is prescribed contact precautions?
Most facilities use disposable thermometer and BP cuffs and have a wall
clock for use, if not use a Ziploc bag before entering room.
Pens should be left in the room and clipboards should be kept outside of
the room.
Two hampers in the room should be used, one for linens and one for
garbage. At the end of the shift the bags should be emptied
A nurse is caring for an adolescent client and is reinforcing education
related to injury prevention. What information should be included?
Keep firearms in a locked cabinet
Teach proper use of sporting equipment prior to use
Insist on helmet us and pads when roller skating, skateboarding,
bicycling and during any other activities that increase injury risk
Avoid trampolines
Beware of changes in mood and monitor for self-harm
What is pulse oximetry and what is a normal finding? What could cause
an abnormal reading?
,Pulse oximetry is a noninvasive measurement of the oxygen saturation
of the blood for monitoring respiratory status
A normal finding is 95% to 100%
The cause of an abnormal reading is hypothermia, poor peripheral blood
flow, too much light, low hemoglobin levels, jaundice, movement,
edema, and nail polish
A nurse is caring for a client with a diabetic ulcer which is has a
bacterial infection. Identify the lab values the nurse will review to
monitor for infection.
Elevated WBC = the expected range is 5,000-10,00
Elevated ESR = expected range is 15 to 20mm/hr
A nurse in the treatment plan of a client with a stage III wound has an
order to irrigate the wound site. Identify nursing measures to safely
clean and irrigate the wound for this client
clean and/or debride the following, prescribed dressing
surgical intervention
proteolytic enzymes
provide nutritional supplements
administer analgesics
administer antimicrobials
To reduce the risk of Hepatitis A transmission identify three (3)
measures use to maintain standard precautions.
A private room or a room with other clients who have the same infection
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag
without touching the outside of the bag
The nurse receives an order to administer enteral tube feedings to a
client with dysphagia. The order states- Administer 1500 mLs of enteral
feeding over 18 hours via infusion pump. What will the mLs per hour
be? Round to the nearest whole number.
1500/15=83
, Name the two (2) preferred sites of an intramuscular injection in an adult
client. When is it recommended to use the larger muscle site?
Ventrogluteal and deltoid
It is recommended to use ventrogluteal site when deltoid is not used.
A nurse is checking the pulse oximetry of a hospitalized client who is on
2 liters of oxygen by nasal cannula. The finger probe is showing 89%
oxygen saturation. Which of the following may produce a low reading?
(Select all that apply).
Hypoxemia
Nail polish
Poor peripheral blood flow
Low hemoglobin
Describe three (3) special considerations when starting an IV on an older
adult client with fragile veins.
Avoid tourniquets
Use a blood pressure cuff instead
Do not slap the extremity to visualize veins
Avoid rigorous friction while cleaning the site
The nurse is caring for a client who has a would drainage device in
place. Discuss the use and benefits of this drainage system.
Promotes drainage of fluid from the incisional site
Decreases pressure on tissues
Decreases abscess formation
Promotes healing from inside out
Reduces bacterial counts through debridement
Promotes granulation
Stimulates cell growth
Focused review funds 2
