Exam 1: NSG3280 / NSG 3280 (Latest 2026/2027 Update) Pathophysiology for Nurses I | Complete Review | Questions & Verified Answers | 100% Correct | Grade A – Galen

Exam 1: NSG3280 / NSG 3280 (Latest 2026/2027 Update) Pathophysiology for Nurses I | Complete Review | Questions & Verified Answers | 100% Correct | Grade A – Galen When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change. C A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body D A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand C, D, E A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash the hands with soap and water for at least 15 seconds C. Rinse the hands with hot water D. Use a clean paper towel to turn off hand faucets E. Allow the hands to air dry after washing B, D A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field C. The procedure is delayed 1 hr because the provider receives an emergency call D. The nurse turns to speak to someone who enters through the door behind the nurse E. The client's hand brushes along the outer edge of the sterile field B, C, D A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A, B, C, E The nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster D A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness D A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate A, B, E A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of a least six exchanges per hour B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when performing care that might result in contamination from secretions B, C, E A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed in its lowest position with all side rails up C. Make sure the clients call light is within reach D. Provide nonskid footwear E. Complete a fall-risk assessment C, D, E A nurse manager is reviewing with nurses on the unit that care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer his medications." D. "I will prepare to insert an airway." B A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit C A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about falls C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aides in his possession A A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following and open reduction internal fixation of the ankle D. An older adult who is postoperative following a below-the-knee amputation D A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No Smoking" sign should be placed on the front door D. Cotton bedding and clothing should be replaced with items made from wool E. A fire extinguisher should be made readily available in the home B, C, E A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has a heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 degrees Fahrenheit." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will place my baby on his stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib." B A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body D A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply.) A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at risk should eat or drink only pasteurized dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning B, C, E A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg B A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed B. Call for additional staff to assist with the transfer C. Use a transfer gait belt and assist the client back to bed D. Determine the client's ability to help with the transfer D A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow. B. Lie flat on her stomach with her head to one side C. Sit on the side of her bead and rest her arms over pillows on top of her bedside table D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her C A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the manager include? (Select all that apply.) A. Request assistance when repositioning the client B. Avoid twisting your spine or bending at the waist C. Keep your knees slightly lower than your hips when sitting for a long time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles A, B, D A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When lifting an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward." B, C, D A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has a partial-thickness and full-thickness burns to his face, neck, and chest D. A patient who has a fractured fibula and tibia C A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) A. Open door to client rooms B. Place blankets over clients who are confined to beds C. Move beds away from windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms B, C, D An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Wash the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive C A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of following statements by a nurse indicates understanding of proper procedure? A. "I will get the caller off the phone as soon as possible to alert the staff." B. "I will begin evacuating clients using elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises." D A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community an that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat small bowel obstruction C. A client who is scheduled for an elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg E. A client who has acute appendicitis and is scheduled for an appendectomy C, D A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and her last name B. Use a mix of open- and closed-ended questions C. Reduce environmental noise D. Have the client complete a printed history form E. Perform a general survey before the examination B, C, E A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as a part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status A, B, C A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skill of the physical examination process should she perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion B A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Collect the data in one continuous session B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take her time answering questions E. Invite the client to use the bathroom before beginning the examination B, C, D, E A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers C A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 degrees Celsius (101 degrees Fahrenheit). pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently A, C, E A nurse is instructing an assistive personnel about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting her respirations." D. "Let the client rest for 5 minutes before you measure her blood pressure." A A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe on full respiratory cycle before counting the rate D. Count the rate for 30 sec if it is irregular E. Count and report any sighs the client demonstrates A, B, C A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for any hypertensive medication B. Ask the client is she is having pain C. Request a prescription fro antianxiety medication D. Return in 30 min to recheck the client's blood pressure B A nurse is performing an admission on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? 16/min A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch." C, E A nurse is assessing a client's thyroid gland as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline A, D, E A nurse is assessing an adult client's internal ear canals with an otoscope as a part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back B. Insert the speculum slightly down and forward C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in) D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape B, C, E A nurse is caring for a client who asks what her Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet. A A nurse is performing a head and neck examination for an older client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums D, E A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion A, D, E A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds C, E During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias C During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur B, D A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits A, B A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill less than 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hand D. Thick skin on the soles of the feet E. Numerous light brown macules on the face A, D, E A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling B, C, D A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply.) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature B, C, E A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella D, E A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema B A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side C, E A nurse is assessing a client's neurosensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30 cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand D A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink C A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply.) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test A, B A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Slower light touch sensitivity B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation B, C, D A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side B. Place two fingers in the client's mouth to open C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth A A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. Use over-the-counter products to treat abrasions E. Wear cotton socks A, B, E A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client A A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms A A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleanser C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them B A nurse in a provider's office is caring for a client that states that, for the past week, she has felt tired during the day and cant sleep at night. Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply.) A. "Does your lack of sleep interfere with your ability to function during the day?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing." A, C, D, E A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) A. Practice muscle relaxation techniques B. Exercise each morning C. Take an afternoon nap D. Alter the sleep environment for comfort E. Limit fluid intake at least 2 hr before bedtime A, B, D, E A nurse is caring for an older adult client who has been following the facilities routine and bathing in the morning. However, at home, she always takes a warm bath before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for sleeping medication C A nurse is preparing a presentation at a local community center about sleep and hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply.) A. REM sleep provides cognitive restoration B. REM sleep lasts about 90 min C. It is difficult to awaken a person in REM sleep D. Sleepwalking occurs during REM E. Vivid dreams are common during REM sleep A, C, E A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day." B A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck when swallowing C. Have the client use a straw D. Encourage the client to lie down and rest after meals B A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates D A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup C A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate her body mass index (BMI) and determine whether this client's BMI indicates that she is of healthy weight, overweight, or obese. 31; Obese A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do C. Many older men and women need calcium supplements D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbohydrates A, B, C A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk for the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure ulcer D. Fecal impaction C A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver B. Apply elastic stockings C. Review laboratory values for total protein level D. Place pillows under the client's knees and lower extremities E. Assist the client to change position often B, E A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr B. Instruct the client to cough and deep breathe every 4 hr C. Restrict the client's fluid intake D. Reposition the client every 4 hr A The nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape." B A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the cane 38 cm (15 in) in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the stronger leg so that it aligns evenly with the cane A, B, D SubQ needle length 1/2"-5/8" SubQ gauge 26-30 SubQ angle 45-90 degrees SubQ volume 1 mL at most IM needle length (deltoid) 1"-2" (5/8"-1") IM gauge (deltoid) 21-23 (23-25) IM angle 90 degrees IM volume (deltoid) 3 mL (1 mL) at most Intradermal needle length 1/2" Intradermal gauge 26-28 Intradermal angle 5-15 degrees SubQ sites Upper arm Abdomen Sub-scapular Anterior thigh Flanks IM sites Dorsogluteal Ventral gluteal Rectus femoris Vastus lateralis Deltoid IM considerations aspiration z track Isotonic solution same osmolarity as blood plasma expands body and fluid without causing a fluid shift from one compartment to another Hypertonic a solution of higher osmotic pressure pulls fluid from the cells causing them to shrink Hypotonic a solution of lower osmotic pressure moves fluid into cells causing them to enlarge Isotonic solutions D5W 0.9 NS LR Hypertonic solutions D10W D5NS D5.45NS D5LR Hypotonic solutions 0.45 NS 0.33 NS IV - small length 1" IV - small gauge 22 IV - medium length 1 1/4" IV - medium gauge 20 IV - large length 1.88" IV - large gauge 14 IV tubing change 72 hours (3 days) IV solution change 24 hours (1 day) IOM stands for_______________________. Institute of medicine _______________ avoiding injuries to patients from the care that is intended to help them. Self-Care According to the National Patient Safety foundation, ______________________ is the prevention of health care errors and the eliminations or mitigation of patient injury caused by health care errors. Patient safety QSEN stands for __________________________. Quality and Safety education for nurses. ____________________ are unintended health care outcomes caused by a defect in the delivery of care to a patient. Health Care errors The three types of health care errors: Omission, commission, and execution errors. Health care errors; ___________________________ wrong action taken _________________________ failure to do the right thing __________________________ Right action, wrong outcome Omission Commission Execution What are the 3 levels of error? _____________________. _____________________. _____________________. Near-miss Adverse event Sentinel event When it comes to placement of error, errors that occur on the procedural level are at the ______________ end of the triangle and errors on the clinical side (point of care) are on the _______________________ end. Blunt Sharp Levels of Error; _______________________________ Error resulted in unintended harm. _______________________________Error did not result in harm. _________________________________ Error resulted in death or catastrophic harm. Adverse event Near-miss Sentinel event _______________ Errors, also known as human errors, are made by those providers (nurses, physicians, etc.) who are providing patient care, responding to patient needs. Active _________________ errors, also known as system errors, are more organizational, contextual, and diffuse in nature or design-related. latent Historically: Culture of blame Focus: ____________________ Goals: ______________________ Who is to blame? Disciplinary Currently: Culture of safety Focus: _______________________ Goals: ____________________ What contributed to the error? Investigating- root cause analysis (learning from errors, instituting corrective measures.) HRO stands for_________________________________________________________. High reliability organizations HROs exhibit___________________ to operations and have the ___________________ to simplify. Sensitivity, reluctance Just culture: Seeks to find________________ between the need to learn from mistakes and the need for disciplinary action against employees. Balance Interrelated concepts to safety: __________________________. _________________________. _________________________. _________________________. Health care quality Communication Collaboration Care coordination The 4 exemplars of safety: ___________________________. ___________________________. ___________________________. ___________________________. Fall prevention Medication administration Care coordination Error reporting. The goal of PRAISE, national safety goals___________________________. To improve patient safety. ANA stands for__________________________________________________. American Nurses Association _______________________ Transmission of medication from location of administration to the blood stream. Pharmokinetics _______________________ The interaction between the medication and its target to produce effects. Pharmodynamics Effects the drugs have on the body: __________________________. Pharmodynamics Effect of the body on drugs: ________________________________. Define- Safety: Freedom from ______________ injuries. (IOM, 2002). "Establishing systems and processes that reduce risk of errors and increase opportunities to identify and intervene if errors occur." Accidental QSEN's focus on the nurses: Knowledge, Skills, and Attitudes ______________________________ When medication molecules pass into the blood from the site of medication administration. Absorption _____________________ is the transportation of medication to target sites/specific sites of action. This depends on physical and chemical properties of medication/characteristics of the medication and the physiology of the person taking it. Distribution Drugs administered _______________ enter directly into the systemic circulation and have direct access to the rest of the body. Drugs administered ______________ are first exposed to the liver and may be extensively metabolized before reaching the rest of the body. IV Orally ____________________ occurs predominantly in the liver. (medications) Metabolism _______________________ occurs under the influence of enzymes that detoxify, break down, and remove active chemicals. Biotransformation Medications are eliminated through the: _________________________. _________________________. __________________________. __________________________. ____________________________. Kidney Liver bowel lungs exocrine glands The __________________________ of a medication determines the organ of excretion. Chemical makeup _____________________________ is an expected or predicted physiological response to a medication. Therapeutic effect ____________________ An unintended, undesirable, often unpredictable effect of a medication. Adverse effect Effects: Predictable, unavoidable secondary effect: _________________. Accumulation of medication in the blood stream: _______________. Overreaction or under-reaction or different reaction from normal _______________. Unpredictable response to a medication: __________________. Side effect Toxic effect Idiosyncratic reaction Allergic reaction True or False: Patient teaching is included in the legal responsibilities of the nurse true True or False: All medication interactions are bad. ______. False Enteral medication routes: ___________________________. ___________________________. ___________________________. ___________________________. Rectal Oral Buccal Sublingual Parenteral medication routes: ___________________________. _____________________________. _____________________________. Injection Inhalation Topical The preferred and safest IM injection site for all adults, children, and infants ________________________. Ventrogluteal IM Injection site often used for infants, toddlers, and children receiving biologicals ___________________________. Vastus lateralis The _______________ method is for IM injections to seal needle track by using a zig zag path Z-track method Intramuscular injections should go in at _______ degrees. 90 Subcutaneous injections should go in at ______ - _______ degrees. 45-90 Intradermal injections should go in at ______ - _______ degrees. 5-15 The risk with IM injections is _______________. Infection Large volume infusions contain _______ to __________ mL 500-1000 Volume controlled infusions contain _________ to _______ mL. 50-100 Changing sites for subcutaneous injections enhances_____________________ and prevents _______________________. Absorption Lipohypertrophy The Rights of medication administration: _________________________. _________________________. _________________________. _________________________. _________________________. Right medication Right dose Right patient Right route Right time Right documentation A small (25 to 250 ml) iv bag or bottle connected to a short tubing line _______________. Piggy back When it comes to pregnant and lactating women the benefits of the medication must ______________ the risks. Outweigh No dorsogluteal injections in infants and children until they can _________________. Walk __________________ effects can cause abnormal fetal development. Teratogenic Patient identifiers: ______________/_________________ and ____________________. NOT_____________________. Name/date of birth and ARM BAND. Not room numbers Which of the following preventing errors in medication administration are nursing roles: Prescribing, transcribing, procuring, dispensing, administering, and monitoring. Transcribing Procuring Administering Monitoring Which type of medication should never be crushed or sprinkled on food: ________________________________. So, if a patient has trouble swallowing pills what should the nurse do? ______________________. Sustained release, Ask physician to change to order Tylenol is an example of the ____________ name of medication whereas acetaminophen is the ________________ name. Trade Generic Glucose regulation is the process of maintaining ______________blood glucose levels Optimal Hypoglycemia is a BG level of less than _________ mg/dL and severe hypoglycemia is less than ____________mg/dl. 70 50 Hyperglycemia post-prandial BG level is greater than _____________mg/dL and sever hyperglycemia BG level is greater than _____________________ mg/dL. 140 180 Euglycemia BG is between ___________ and_____________ mg/dL before and after eating. 70 - 140 ______________ cells secret glucagon when blood glucose levels drop. Alpha The _______________ releases growth hormone-releasing hormone (GHRH). Hypothalamus Which hormone lowers glucose? ____________________. Insulin Counter regulatory hormone that raise glucose __________________ and ________________________. Glucagon Cortisol Short term consequences of hyperglycemia: ______________________________________________________. ______________________________________________________. Inadequate glucose reaching the cells Dehydration Long term consequences of hyperglycemia: ____________________________________________________________ ___. ____________________________________________________________ ___. End-organ disease due to microvascular damage Macrovascular angiopathy The American Diabetes Association and the American Association of clinical Endocrinologists emphasize an __________________________ approach to medication therapy for those with diabetes. Individualized ________________________ are used in the treatment of type 2 diabetes, and help manage glycemic control by reducing insulin resistance and enhancing insulin secretion. Oral hypoglycemic agents NPH- Onset of action ________-_________ hr., peak of Action __________ to __________hr., and duration of action up to_______________hr. 1.5-4h 4-23h 24h Glargine - onset of action _______ - ______ hr., peak of action___________, Duration of action up to ___________hr. 45m-4h minimal 24h Regular (Humulin R and Novolin R) - Onset of action ________-_________ min, Peak of Action _________-_________ hr., and Duration of Action up to ____________hr. 30-60m 2-5h 24h Aspart (Novolog), Lispro (Humalog), Glulisine (Epidra) - Onset of Action ______ ______ min, Peak of action _______-_____ h, duration of action ________ _______ hr. 10-30m .5-3h 3-5h Degludec (Tresiba) - Onset of Action _________hr., Peak of action _________hr., and duration of action _________________hr. 1h 12h 42h Short-acting insulin names: _________________________________. _________________________________. __________________________________. Lispro, Aspart, Glulisine True or False: You can freeze insulin_____________. False True or False: You can use insulin if it is expired__________________. False True or False: You should inspect insulin before each use___________________. True True or False: Insulin pens must be refrigerated_________________. False True or False: The insulin pen insulin should look uniformly cloudy/milky___________________. True Four functions of the skin: _______________________________. _______________________________. _______________________________. _______________________________. Protection Excretion Absorption Secretion ________________________ is the state of structurally intact and physiologically functioning epithelial tissues such as integument and mucous membrane. 1. Tissue integrity Populations at greatest risk of impaired tissue integrity: ______________________. _____________________. _____________________. Infants, children, older adults _________________________ are tissue injuries from unrelieved pressure or friction over bony prominences. Pressure ulcers What is the name of the risk assessment scale for pressure ulcers? Braden's Stages of pressure Ulcers: Stage1:__________________________________________________. Stage 2: __________________________________________________. Stage 3: ____________________________________________________. Stage 4: __________________________________________________. Skin is unbroken but inflamed, skin is broken to epidermis or dermis, ulcer extended to subcutaneous fat layer, ulcer extends to muscle or bone (undermining is likely). In terms of depth of wounds, what are the two types of thickness wounds? · ________________________________ · ________________________________ Partial Full When it comes to wound healing; what are the phases, how long do they last, and what happens during the phase? Phase: ____________________________________________. Lasts for: ______________________________. What happens: ___________________________________________ Phase: ____________________________________________. Lasts for: ________________________________________________. What happens: __________________________________________________________. Phase: ____________________________________________. Lasts for: ______________________________. What happens: _________________________________________________________. Inflammatory, 3-5 days, homeostasis develops, macrophages remove debris. Granulation phase, 5-21 days, new blood vessels and tissue are formed. Maturation phase, last for months, collagen fiber is remodeled, scar formation and contraction occur. What factors affect wound healing? _____________________________________. _____________________________________. ____________________________. ______________________________. __________________________________. Age Tissue perfusion Comorbities Medications Nutritional status. What does ABCDE stand for, for skin cancer screening? A: B: C: D: E: Asymmetry, border, color, diameter, evolution. Complications of wound healing; ______________________________ is partial or total separation of wound layers. Dehiscence Complications of wound healing; ______________________________ is protrusion of visceral organs through wound openings. Evisceration Interventions for pressure ulcers; Reposition the client at least every _____ hours. Obtain __________, if drainage is present. Teach the client to _________ frequently Ensure adequate nutrition, add __________ to the diet. Minimize direct ___________. 2, C&S, move, protein, pressure