NURS 100 fundamental final Questions & Answers

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the clients understanding of the process within the psychomotor domain of learning? - ANSWERSHave the client demonstrates the procedure a nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? - ANSWERSPosition the client on his left side A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? - ANSWERSObserve the rate, depth, and character of the client's respirations. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? - ANSWERSSit at the bedside while feeding the client. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? - ANSWERSlower the client to the floor and place a pad under the client's head. a home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? - ANSWERSEducating clients about the recommended immunization schedule for adults. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? - ANSWERSThe AP hangs the collection bag at the level of the bladder. timeframes for STAT, rountine, and now orders - ANSWERS5 mins for stat 30 before/after for rountine 90 minutes for now orders A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? - ANSWERSwashing dishes A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? - ANSWERSrepeat each joint motion five times during each session. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care?(select all that apply.) - ANSWERSProvide oral hygiene frequently measure the drainage from the NG tube every shift Secure the NG tube to the client's gown An example of situational crisis and who is at highest risk - ANSWERSunanticipated loss caused by external factor, and someone with mental health issues. patient education for aspirin and acetaminophen is - ANSWERSreports bleeding, ringing in ear, and not taking if 19 with viral infection (aspirin). avoid alcohol, do not exceed 3gm/day, and routnine blood pressure (acetaminophen) Name and describe 4 landmarks for IM injections - ANSWERSDeltoid vastus lateralis ventrogluteal dorsogluteal determining orthostatic hypotension - ANSWERSTechnique: BP & HR in supine then change to sitting/standing (wait 1-3 mins) BP & HR if SBP dec. More than 20 mm hg and/or DBP dec. more than 10 mm hg w/ a 10-20% inc. in hr=orthostatic hypotension Diet should include this to help in wound healing - ANSWERSProtein What solution is used to clean wound before obtaining specimen? - ANSWERS0.9% sodium chloride (normal saline) Describe dehisence/evisceration and nursing interventions - ANSWERSDehisence partial or total separation of wound and evisceration os dehisence with protrusion of viseral organs through wound opening. Medical emergency, cover wound with moistened sterile gauze. What are the five types of wound exudate (drainage and describe? - ANSWERSSerous(clear, watery), purulent (yellow/green/brown), serosanguineous (pink watery), sanguineous(red), and purspsanguineous (pus and blood)?s name and describe each pressure ulcer - ANSWERSStage I (erythematous non-blanchable) Stage II (exposed dermis-partial thickness loss) Stage III (subcutaneous tissue, full-thickness loss, r) Stage IV ( muscle, tendon, bone, full-thickness loss, slough/eschar), unstageable (can't determine extent, full-thickness, need to do) AND stands for - ANSWERSallow natural death Four CS of a cultural/spiritual assessment is? - ANSWERSCall Cope Concerns Cause Main difference between palliative care and hospice care? - ANSWERSless than 6 months to live 5 Stages of grief - ANSWERSDABDA Denial, anger, bargaining, depression and acceptance 5 clinical manifestations at the end of life and 3 nursing interventions - ANSWERSCheyne stokes (death rattle) Tacky brady, hypotension, diminshed reflexes, mottling skin, decreased urine output, incontinence, muscle loss, anxiety and life review.... Symptom management (pain control), keep clean, elevate HOB, and collaborative care Difference between enteral and parenteral nutrition - ANSWERS(enteral) is entering the GI tract (parenteral) is entering the blood stream Complications with enteral nutrition (3) - ANSWERSaspiration, diarrhea, delayed gastric emptying, skin irritation and dehydration Four nursing interventions to prevent cauti's - ANSWERSonly when necessary, sterile technique on insertion, peri care at least Q8H, hang bag below bladder, increase fluids and only good for 30 days. Normal Urine output is? - ANSWERSGreater than 30 Ml/Hr and 0.5 Ml/Kg/Hr Nursing interventions with enteral nutrition (6) - ANSWERSassessing placement, tolerance (residual checks Q4-6H), label date, time, and initials when opening bag, only hang for 24 hrs with tubing, water flush 30 ml Q4-6H, glucose checks Q6H, I & O, VS, and daily wts Three common nursing interventions for FVD and FVE - ANSWERSVS, I&O and daily weights explain chovstek's and trousseau's sign and what two electrolyte imbalances are they positive for? - ANSWERSTouch the cheek (facial twitching), hypocalcemia Inflate BP cuff (carpal spasm) and hypomagnesemia. what are two nursing interventions only for fluid volume excess - ANSWERSFluid restriction and diuretics