Archer Review Notes 1

05/24/23

For a fire, the nurse should first do what?

Evacuate the client(s) closest to the fire → Then, the nurse should evacuate the clients that are the most ambulatory. These individuals may assist others with ambulation out of the facility

Hypoactive bowel sounds immediately following anesthesia is expected or not?

IS EXPECTED b/c anesthesia decreases peristalsis. Absent bowel sounds would be a concerning finding.

Procedures requiring a sterile approach include

Central line dressing changes, insertion of an indwelling urinary catheter, and suctioning of a tracheostomy (that is not in-line) → In open suctioning, the client is not connected to a mechanical ventilator - this requires a sterile technique

In in-line suctioning, the client is connected to the ventilator, and suctioning can be accomplished via a one-way valve

this does not require a sterile technique because the catheter is wrapped in a protective coating

Haemophilus influenzae, type b Meningitis requires

Droplet precautions…Droplet precautions require the nurse to don a surgical mask upon entry to the client’s room

Patients about to undergo a suctioning procedure should first be what?

Hyper-oxygenated → Suctioning interrupts the patient’s breathing, so hyperoxygenation prevents harm

Expected post-operative drainage

Transitioning from sanguineous (bloody) to serosanguineous (yellowish mixed with light red or pale pink) to serous (serum-like, or yellow) is normal during the first few days. Crusting on the incision line is normal, as is a pink color to the line itself, which is caused by inflammation from the surgical procedure

Unexpected post-operative drainage

Redness or swelling of or around the incision line, excessive tenderness or pain on palpation, and/or purulent or odorous drainage indicates surgical site infection (SSI) and must be reported to the primary healthcare provider (PHCP).

Impetigo

A contagious skin condition that is caused by Staphylococcus aureus or Streptococcus pyogenes (Contact precautions) → this condition is commonly found in young children and typically presents around the face, mouth, and then on the hands, neck, and extremities → The lesions have drainage and then begin to crust

Orthodox Judaism diet

Do not eat meat with dairy products in the same meal → Orthodox Judaism only allows for the consumption of Kosher animals

A cheiloplasty is a procedure to repair a cleft lip (CL)

This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke → Prevent respiratory distress

The basic crutch stance (commonly referred to as the tripod stance)

15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot → Two to three finger widths should be between the crutch pad and the client's axilla → The client should avoid crutches on wet surfaces because of the risk of falling. If the crutch tips become wet, the client should be instructed to dry them promptly with a paper towel.

Adequate oral hygiene

Helps clear the airway, reduces infection risk, and supports client comfort and self-esteem. When performing oral care, it is important to use a sponge cleaner or soft-bristled toothbrush with water.

Glycerin swabs and alcohol-containing mouthwash products

can alter the mouth's pH and dry out the mucous membranes, leading to increased bacterial growth

If ordered, diluted hydrogen peroxide solutions can help with what?

Help address crusted areas

Isometric exercises

involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall

When cleaning the labia with the antiseptic solution, the student should

Wear sterile gloves to clean the labia with their dominant hand while separating the labia with the fingers of the nondominant hand to fully expose the urethral meatus. Acting correctly will greatly decrease the risk of contamination. Asking the client to bear down gently and slowly insert the catheter through the urethral meatus is appropriate because it relaxes the external urinary sphincter, which facilitates the passage of the tubing.

The drainage bag of the urinary catheter should not be secured to the bed's side rails b/c

it will move and cause tension on the tubing that may cause urinary trauma (should be secured to the bed’s frame below the bladder)

Due to the nutritional needs of clients requiring total parenteral nutrition (TPN), formulations of TPN typically contain

a high concentration of dextrose (typically 10% to 50%), leading to an increased predisposition to catheter-related bloodstream infections. To prevent these infections, an aseptic technique is utilized.

→ TPN should never hang for more than 24 hrs

→ Lipids should not hang for more than 12 hrs

Excessive corticosteroids characterize Cushing's syndrome

Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence.

“CUSHING”

Central obesity, Urinary free cortisol, Suppressed immunity, Hypercortisolism, hypertension, & hyperglycemia, iatrogenic, noniatrogenic, glucose intolerance

H. pylori infections

transmitted predominantly by contaminated water. H. pylori can spread within the families through close contact among family members (Standard precautions)

Contact Precautions

(Hand hygiene->Gown->Gloves->Dedicated disposable equipment->Private room/ cohort pt w/ same infection): MRSA, VRE, Conjunctivitis, Diphtheria (cutaneous), Respiratory Syncytial Virus (RSV), Herpes Simplex Virus, Human Metapneumovirus, Pediculosis (lice). Scabies, Poliomyelitis, Staphylococcus aureus, C.difficile, Norovirus, Rotavirus

Droplet Precautions

(Hand hygiene->Mask->Private room/ cohort w/ same infection): Influenza, Pertussis, Mumps, Rhinovirus, Adenovirus, Rubella, Epiglottis, Parvovirus, Bacterial meningitis (not viral), Haemophilus influenzae type B, Diphtheria (pharyngeal)

Airborne Precautions

(Hand hygiene->N-65 Mask->Private, negative pressured room w/ door closed->Gown & gloves if potential contact w/ bodily fluids): TB, Rubeola virus (measles), Varicella virus (Chickenpox), SARS, Smallpox, Disseminated Varicella Zoster Virus (VZV)

Wheezing

creates squeaky, musical, continuous sounds associated with air rushing through narrowed airways; it may be heard without a stethoscope. Wheezes originate from the small airways and usually do not clear with coughing. Treatment for wheezing is bronchodilators and inhaled anticholinergics

Pleural friction rub

characterized by loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together, often associated with pain on deep inspirations

Stridor

a medical emergency and indicates that the upper airways (larynx or pharynx) are closing

Coarse crackles

lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways, likely to change with coughing or suctioning

Fine crackles

sound like popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear

Rhonchus (rhonchi)

lower in pitch and sounds like continuous snoring. These sounds arise from the large airways and usually can be cleared with coughing

Fire Emergency Response “RACE”

Rescue (rescue others in immediate danger), Alert (Shout Fire! Fire! (or) Pull fire alarm (or) Dial an emergency phone number, Contain (close all doors and windows), Extinguish/Evacuate (Extinguish small fires, evacuate clients if appropriate)

The first bodily area to be washed with a complete bed bath is

the inner canthus of either eye, including the right or left eye. The washing is done from the inner to the outer canthus of the eye. The next steps for the bath are the rest of the face, the upper chest, the arms, and hands, after which you would proceed downward on the body from the head to the toes.

Nasogastric (NG) Tube

Purpose: Put things IN or take things OUT of the stomach (commonly used for enteral feedings & enteral medication administration) ->supine w/ the head of the bed 90 degrees

Size: Variety of sizes- smaller the number = smaller the tube (6 Fr tubes- for small babies -> 14 Fr tubes- for big adults!)

Number of lumens: ONE

Salem Sump Tube

Purpose: Decompression- take things OUT of the stomach! (Several holes alongside to maximize decompression)

Size: Usually a large bore tube- 16 Fr is very common

Number of lumen: TWO- one for suctioning, the other is a vent to allow pressure to equalize

A wet-to-dry dressing is a dressing that provides a type of mechanical debridement

The dressing should consist of one continuous length of gauze

Utilize the expertise of wound care clinicians in the treatment of pressure ulcer clients.

Pressure injuries can develop secondary to immobilization and hospitalization, particularly in clients who are elderly, incontinent, and/or undernourished.

Base the risk of pressure injury on standardized scaling systems and on the assessment of skilled clinicians.

The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin…Should NOT do what?

Wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound

Preeclampsia Classic Triad “PREeclampsia”=

Proteinuria, Rising BP, Edema

Seizure Precautions

Maintain patient airway!: Ensure O2 & suctioning equipment w/ airway available at bedside

Ensure IV access (or insert saline lock): IV drug therapy may be needed to stop seizure

Promote client safety: Bed in lowest position/ Pillow under head/ Padded side rails

Primary prevention

Intervening before an individual has a health issue

\-Education

\-Immunizations

Secondary Prevention

Early identification of the disease

\-Screenings

\-Health Fairs

Tertiary Prevention

Treats the disease and prevents further complications

\-Nutritional education for someone w/ CHF

A patient with low blood pressure and tachycardia after a surgical procedure may be experiencing an illness. (Pt may have…?)

Hemorrhage → Blood loss results in lowered blood pressure and the heart rate increases to compensate

Wound dehiscence

occurs when the edges of a surgical site rupture (requires immediate treatment)

The development of an infection after surgery

usually presents with tachycardia and fever. Hypotension may or may not be present.

Medications that may raise the risk for falls include

Any agents that may cause drowsiness (benzodiazepines, opioids), shifts in blood pressure (diuretics, beta-blockers), or alterations to the sensorium (melatonin). The nurse should diligently work to ensure a safe environment for the client and assess their risk for falls.

Examples: Alprazolam (benzodiazepine), Bumetanide (loop diuretic), Verapamil (calcium channel blockers)

Preoperative state

The client has been NPO for approximately eight hours, sufficient time to prevent aspiration

MRI

Uses magnetic fields & radio waves to generate 3D anatomical images

Lasts 15-60 minutes

May show soft tissue/organ changes

Great for brain, spinal cord, & nerves

May or may not use contrast

Ensure client has no metal objects in/on them

Assess for claustrophobia

Check if client has pacemaker (old machines may deactivate pacemakers)

Contraindications: agitation, old tattoos (may contain lead)

Contralateral stimulation

involves stimulating the skin in an area opposite to the painful site. The stimulation may be in the form of scratching, rubbing, or applying heat or cold. This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast.

Daily cleaning of the urinary meatus is recommended w/

Soap and water for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

An expected outcome that is appropriate for the recipient of respite care

“The primary caregiver will be physically and emotionally rested.” : Respite care provides time off for the primary caregiver of the ill client so that the caregiver gets to rest with the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver.

To test for accommodation…

the nurse should darken the room and ask the client to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 4 inches from the bridge of the client's nose. The pupils normally converge and accommodate by constricting when looking at close objects.

Shining the light in the pupil is a test for

pupillary responses

Visual acuity

tested using a Snellen chart where the client is asked to stand twenty feet away from an object, and they are asked to read the smallest possible line

Pupil exam “PERLA”

Pupils Equal Round & Reaction to Light & Accommodation

Usually, only sufficient fluid to lubricate the pleura is present in the pleural cavity. However, excessive fluid can accumulate as a result of injury, infection, or other pathology. In such a case of pleural effusion or pneumothorax, the physician may perform a thoracentesis to remove the excess fluid or air to ease breathing → Thoracentesis procedure

The patient should be sitting up, leaning over a bedside table with arms rested, feet supported on the ground, or stool so the needle can be inserted appropriately.

Walking w/ a cane “COAL”

Cane Opposite Affected Leg

Using the stairs: " Up with the good, and down with the bad" is a good statement while educating the client regarding cane usage to navigate the stairs.

→ Up with the good: If the client must ascend stairs, the nurse should instruct the client first to hold the cane on their stronger side.

Then the client should advance the unaffected (good) leg onto the step and, following that, move the affected (weaker) leg and the cane simultaneously onto the step.

The cane and the weaker side should always move together.

→ Down with the bad: If the client must descend stairs, the nurse should instruct the client to hold the cane on their stronger side. The client should simultaneously place the cane and the affected (weaker) leg down on the next step, followed by the unaffected (stronger) leg.

Common medications utilized for moderate (conscious) sedation include

Fentanyl, midazolam, or propofol.

\-CNS depressants, and during the procedure, the client is often given supplemental oxygen

\-Post-procedurally, the nurse will monitor the client’s vital signs very closely

Assessing the client's oxygen saturation is essential because

Early signs of hypoxia include altered mental status and restlessness should be assessed

Trying to stop or minimize a fall can cause the nurse injury. An approach that may be used to minimize injury during a fall is where the nurse…

Assumes a wide base of support with one foot in front of the other, thus supporting the client's body weight. Allowing the client to slide down one leg can reduce injury to the client.

The Amish community prides itself in taking a simple approach to their lifestyle:

\-The family structure is generally large, and family is important

\-The male is considered the head of the household and generally makes key decisions

\-Natural remedies and treatments are often pursued in this community

\-Most of the community is rejects health insurance

\-Organ transplantation and blood transfusion is not prohibited

\-Church and religion are fundamental in their community

The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with

A. heart failure receiving diuretics

B. bacterial meningitis receiving antibiotics

C. prostate cancer receiving brachytherapy

D. varicella prescribed antivirals

**Choice A is correct.** Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate client to room with would be an individual receiving intravenous diuretics for heart failure as this client does not have any transmissible pathogens.

The nurse is supervising a new nurse caring for an elderly client. Which of the following statements regarding sensory changes in an older adult, if made by the new nurse, would **require follow-up**? Select all that apply:

Increased acuity for high-pitched tones.

Decreased sensitivity to glare.

Increased tympanic membrane flexibility.

Diminished sound discrimination.

Decreased taste reception.

**Choices A, B, & C are correct.** These statements are incorrect regarding changes in the older adult and, therefore, require follow-up by the supervising nurse.

* Older adults commonly experience **a loss of acuity** for **high-pitched** frequencies ( **presbycusis**) due to changes in the inner ear, such as sclerosis ( Choice A).
* Glare sensitivity is increased, not decreased. As adults age, changes in the eye, such as *smaller pupils* and *reduced light accommodati*on, can result in **increased sensitivity to glare** ( Choice B)**.**
* Age-related changes in the **ear** also include a **thickening of the tympanic membran**e rather than increased flexibility ( Choice C).

The nurse is caring for assigned clients. Which client should be evacuated **first** during a fire? A client with

A. below-the-knee amputation receiving patient-controlled analgesia.

B. acute respiratory distress syndrome receiving mechanical ventilation.

C. advanced dementia receiving enteral feedings and intravenous fluids.

D. acute glomerulonephritis with an indwelling urinary catheter.

**Choice D is correct.** When evacuating clients from a fire, the nurse should evacuate the client closest to the fire. Once that has been completed, the nurse should evacuate the most ambulatory client. The client with acute glomerulonephritis only has one device, and the nurse can quickly change the system to a leg bag or instruct the client to keep the bag below their bladder.

Which of the following is a neurological complication that may occur when a vest restraint is too tight around a patient’s body?

A. Skin breakdown

B. Strangulation

C. Changes in skin pallor

D. Numbness

**Choice D is correct.** The neurological complication can occur when a vest restraint is too tight around the client’s body causing numbness and tingling that, unless corrected, can lead to neurological damage.

The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home? **Select all that apply.**

Positive gag reflex

Hypoactive bowel sounds

Blood pressure 90/60 mm Hg

Incisional pain '2' on a scale of 0 to 10

Urinary output of 240 mL since surgery

**Choices A, B, D, and E are correct.** This client data reflects that the client is ready for discharge home. The client has a positive gag reflex, adequate urinary output (UOP) for the postoperative time frame (> 30 mL/hr), positive bowel sounds, and minimal pain. The client's UOP is high, but it is only would be concerning if it were low. Intraoperative IV fluids may be given to explain the surgery that explains the increased UOP. __Hypoactive bowel sounds immediately following anesthesia is expected because anesthesia decreases peristalsis__. **Absent bowel sounds would be a concerning finding**. The client's pain is minimal and does not inhibit their ability to be discharged.

The nurse is conducting an in-service for nursing students. It would be appropriate for the nurse to state which of the following procedures requires a sterile technique? **Select all that apply.**

Changing the dressing for a central line

Inserting an indwelling urinary catheter

Removing a peripheral vascular access device

Suctioning an endotracheal tube with in-line suction

Inserting a nasogastric tube (NGT)

**Choices A and B are correct.** Dressing changes of central lines requires a sterile technique. Central lines include ports, peripherally inserted central catheters and intrajugular access. An indwelling urinary catheter insertion requires a sterile technique to prevent urinary infection.

The nurse plans care for a client admitted with *Haemophilus influenzae*, type b Meningitis. When caring for this client, the nurse should gather which appropriate personnel protective equipment (PPE)?

A. Boot (shoe) covers

B. Face shield

C. Surgical mask

D. Gown

**Choice C is correct.** Haemophilus influenzae, type b Meningi requires droplet precautions. Droplet precautions require the nurse to don a surgical mask upon entry to the client’s room. Cohorting with droplet precautions is permitted as long as the other individual has the same pathogen. Clients who require transport or want to ambulate outside their room should don a surgical mask.

The nurse is preparing to suction a client to obtain a sputum sample. Before performing this procedure, the nurse should:

A. Hyperoxygenate the client

B. Provide the client with a small snack

C. Initiate NPO status

D. Confirm the order with the physician

**Choice A is correct.** Patients about to undergo a suctioning procedure should first be hyper-oxygenated. Suctioning interrupts the patient’s breathing, so hyperoxygenation prevents harm.

The nurse is triaging a child with suspected impetigo. Which action should the nurse take? **Select all that apply.**

Initiate droplet precautions

Set up a decontamination room

Use a disposable blood pressure cuff

Initiate contact precautions

Apply sterile gloves while examining the client

**Choices C and D are correct.** Impetigo is a contagious infection of the skin commonly seen in young children. This condition is highly infectious, and the nurse should utilize standard and contact precautions. Part of this involves using disposable client care equipment (blood pressure cuff, thermometer, etc.). Contact precautions require the nurse to wear a gown and gloves when engaging in client care.

Select the classification of cultural beliefs/practices that are accurately paired with an example of it.

A. Holistic health beliefs: A pathogen causes infection and this leads to health problems.

B. Magical health beliefs: Illness results from disharmony of the body and the mind.

C. Scientific health beliefs: The wearing of an amulet to protect health.

D. Scientific health beliefs: Compliance with the medical regimen is essential to health.

**Choice D is correct.** Scientific health beliefs are grounded in scientific research and evidence-based practice. With research and science, we can know the etiology of diseases and also ways to treat illnesses/disorders. Therefore the clients’ compliance and adherence to the medical regimen are essential to health and recovery.

The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?

A. Nasogastric tube (NGT)

B. Bottle of sterile water

C. Suction equipment

D. Tracheostomy

**Choice C is correct.** A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress.

The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student

A. positions the handgrips so that the axillae support the client's body weight.

B. demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot.

C. observes two to three finger widths between the crutch pad and the client's axilla.

D. instructs the client to dry crutch tips with a paper towel if they become wet.

**Choice A is correct.** This action is incorrect and requires follow-up**.** This is an incorrect positioning for crutches, as the axillae should **not** support the client's body weight. The hands should support the client's body weight as weight supported in the axilla may cause nerve injury.

The nurse provides oral care to clients in the ICU. What are the benefits of providing oral care to a client in critical care? **Select all that apply.**

It promotes the patient’s sense of well-being.

It prevents deterioration of the oral cavity.

It decreases the incidence of aspiration pneumonia.

It eliminates the need for regular flossing.

It decreases oropharyngeal secretions.

It compensates for an inadequate diet.

**Choices A, B, and C are correct.** Adequate oral hygiene is essential for promoting a client's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of both aspiration pneumonia and ventilator associate pneumonia (VAP).

The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client

A. exercises both extremities simultaneously.

B. knows their heart rate should be monitored while exercising.

C. practices forced resistance against stable objects.

D. swings their limbs through the full range of motion.

**Choice C is correct.** Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall.

The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? **Select all that apply.** The student

applies clean gloves to clean the perineal area with soap and water.

asks the client to bear down gently and slowly insert the catheter through the urethral meatus.

separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.

secures the catheter tubing to the inner thigh.

attaches the drainage bag to the side rails of bed.

**Choices C and E are correct.** These actions by the student are incorrect and require follow-up by the nurse. When cleaning the labia with the antiseptic solution, the student should wear **sterile gloves** to clean the labia with their **dominant** hand while separating the labia with the fingers of the **nondominant hand** (now contaminated) to fully expose the urethral meatus. Acting correctly will greatly decrease the risk of contamination. The drainage bag of the urinary catheter should not be secured to the bed's side rails as it will move and cause tension on the tubing that may cause urinary trauma.

A nurse is caring for a client receiving total parenteral nutrition (TPN). Strict surgical asepsis is required when changing TPN dressings and tubing because:

A. The TPN requires refrigeration, and once the TPN is opened and is no longer refrigerated, it presents a risk for infection.

B. The presence of manganese and zinc in TPN increases the risk of infection.

C. The magnesium and cobalt often present in TPN increases the risk of infection.

D. The high concentration of dextrose in TPN increases the risk of infection.

**Choice D is correct.** Due to the nutritional needs of clients requiring total parenteral nutrition (TPN), formulations of TPN typically contain a high concentration of dextrose (typically 10% to 50%), leading to an increased predisposition to catheter-related bloodstream infections. To prevent these infections, aseptic technique is utilized. 

Select the parenting style that is accurately paired with one of its advantages.

A. The democratic style of parenting: It is relatively quick and easy to solve problems.

B. The autocratic style of parenting: It gives the impression that the family is strong.

C. The permissive style of parenting: It facilitates satisfaction among the members of the family.

D. The laissez-faire style of parenting: It gives the impression that the family is loving.

**Choice C is correct.** The permissive style of parenting, like other parenting styles, has its advantages and its disadvantages. The permissive style of parenting facilitates satisfaction among the members of the family, however, it is disadvantageous because it can lead to undesirable behaviors because young children of the family may need more structure and clearer boundaries to develop appropriate behaviors.

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?

A. Diabetes insipidus

B. Cushing's syndrome

C. Hemophilia

D. Inflammatory bowel disease

**Choice B is correct.** Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence.

The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with

**Select all that apply**

H. pylori placed on standard precautions.

rotavirus provided a disposable blood pressure cuff.

rubella and their door is kept closed.

influenza ambulating in the hall with a surgical mask.

Legionnaires’ disease placed on contact precautions.

**Choices C and E are correct.** These observations are inappropriate and require follow-up. The door should be closed in airborne isolation precautions, not droplet precautions. A client with rubella should be placed on droplet precautions. The minimum PPE required for droplet precautions is a surgical mask. Legionnaires’ disease is not transmitted person-to-person but rather through infected water or soil. This bacterium requires standard precautions.

The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up?

A. "Wheezes arise from the small airways and usually do not clear with coughing."

B. "A pleural friction rub causes loud, rough, scratching sounds usually during inspiration."

C. "Thick, tenacious secretions that clear with coughing cause crackles."

D. "Fluid or secretions in large airways typically cause coarse crackles."

**Choice C is correct.** This statement requires follow-up because it is incorrect. Thick, tenacious secretions that clear with coughing cause *rhonchi*.

The first bodily area to be washed with a complete bed bath is the:

A. Inner canthus of the right eye

B. Cheeks

C. Forehead

D. Chin

**Choice A is correct.** The first bodily area to be washed with a complete bed bath is the inner canthus of either eye, including the right or left eye. The washing is done from the inner to the outer canthus of the eye. The next steps for the bath are the rest of the face, the upper chest, the arms, and hands, after which you would proceed downward on the body from the head to the toes.

The nurse is using the therapeutic communication technique while caring for her prenatal client. Which phrase, when used by the nurse, is an example of "focusing"?

A. “You’re afraid your baby will be born after your due date. Is that correct?”

B. “I’ve noticed a lot of bruising on your arms.”

C. “What would you like to talk about during our appointment today?”

D. “Earlier you mentioned feeling scared at home. I’d like to talk about that a bit more. What is causing you to feel scared at home?”

**Choice D is correct**. Saying, “Earlier you mentioned feeling scared at home. I’d like to talk about that a bit more. What is causing you to feel scared at home?” is an example of a therapeutic communication technique known as "**focusing**". During conversations, patients may mention certain issues that are important to them. When this happens, nurses can focus on the client's self-perceived priorities, prompting them to discuss issues further.

The nurse is preparing to insert a nasogastric tube (NGT) for a client with abdominal distention. The nurse should place the client in which position for this procedure?

A. Supine with the head of the bed elevated at 30 degrees

B. Supine with the head of the bed 90 degrees

C. Left-lateral position with the knees bent

D. Right-lateral position with the knees bent

**Choice B is correct.** This positioning is appropriate when placing an NGT. Placing the client in this position promotes the client's ability to swallow during the procedure. The nurse should place the pillow behind the client's shoulder blades to allow the client to flex and extend their neck.

A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?

A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer.

B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing.

C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin.

D. The registered nurse saturates the old dressing with sterile saline before removing it.

**Choice C is correct.** The wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound.

The nurse is caring for a 7-year-old child who is continuously anxious in the pediatric ward. The nurse plans to initiate therapeutic play to help the child's anxiety. During the therapeutic game, all of the following activities should be included, **except**:

A. Encourage manipulation of equipment.

B. Constantly monitor the child’s anxiety levels throughout the activity.

C. Provide structure for the play.

D. Continue play sessions regularly.

**Choice C is correct.** All the other statements are accurate *except* option C. Therapeutic play should be **unstructured**. The child should use the equipment, however, or whenever he/she wants it.

The nurse is caring for a client admitted with severe pre-eclampsia. It would be **essential** for the nurse to have which of the following items at the bedside? 

A. One liter of 0.9% saline

B. Sterile gloves

C. Portable ultrasound

D. Suction equipment

**Choice D is correct.** A client with severe pre-eclampsia should be monitored closely for seizures which are the hallmark manifestation of eclampsia. The nurse should plan care involving seizure precautions at the bedside, including suction equipment, padded side rails, and oxygen.

The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?

A. The development of an infection

B. Hemorrhage

C. Wound dehiscence

D. Hematoma

**Choice B is correct.** A patient with low blood pressure and tachycardia after a surgical procedure may be experiencing an illness. Blood loss results in lowered blood pressure and the heart rate increases to compensate.

The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications can increase the risk for falls? **Select all that apply.**

Naproxen

Alprazolam

Bumetanide

Verapamil

Allopurinol

Thiamine

**Choices B, C, and D are correct.** Medications that may hasten the risk for falls and included benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly.

The nurse supervises a student nurse prepare a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student

A. asks the client if they have claustrophobia.

B. instructs the client to apply earplugs before the exam.

C. moves the nitroglycerin patch from the torso to the back.

D. tells the client that they will not have any exposure to radiation.

**Choice C is correct.** Nitroglycerin transdermal patches should be temporarily removed during the procedure because they may burn the client. The transdermal patch may contain aluminum which is contraindicated for an MRI. Moving the patch would not be helpful as it should be totally removed during the procedure.

You are caring for a client who has severe burns on her right arm and is in extreme pain, despite receiving a potent analgesic. You decide to rub the client's uninjured left arm to relieve pain in the right. This approach is known as which of the following?

A. Massage

B. Contralateral stimulation

C. TENS

D. Acupressure

**Choice B is correct.** Contralateral stimulation involves stimulating the skin in an area opposite to the painful site. The stimulation may be in the form of scratching, rubbing, or applying heat or cold. This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast.

The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include?

A. Sterile gloves should be used to perform urinary catheter care.

B. Urinary specimens may be collected from a catheter bag.

C. You may irrigate a catheter with warm water for poor outflow.

D. Daily use of soap and water should be used around the urinary meatus.

**Choice D is correct.** Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

You have offered one of your newly admitted clients a partial bed bath. The client states, “I took a bath at home three days ago. I do not need a bath for another 3 or 4 days.” How should you respond to this client? You should respond by saying:

A. “Would it be okay with you if I teach you about the benefits of and the need for daily bathing?”

B. “That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath?”

C. “A once a week bath is not good. You have to bathe at least every other day to protect against infection.”

D. I am sorry but we have rules here. All clients must be bathed at least every other day. Let’s start the bath.”

**Choice B is correct.** You would respond with, “That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?” when one of your newly admitted clients refuses a partial bed bath by stating, “I took a bath at home three days ago. I do not need a bath for another 3 or 4 days.” This response acknowledges the fact that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. Clients should be assessed for their bathing needs in preferences of their type of bathing and time of bathing. Additionally, a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic.

An expected outcome that is appropriate for the recipient of respite care is:

A. The terminally ill client will be free of any physical, psychological, or spiritual distress.

B. The terminally ill client will be free of any pain or discomfort at the end of life.

C. The primary caregiver will be free of any physical, psychological, or spiritual distress.

D. The primary caregiver will be physically and emotionally rested.

**Choice D is correct.** An expected outcome that is appropriate for the recipient of respite care is that “the primary caregiver will be physically and emotionally rested.” Respite care provides time off for the primary caregiver of the ill client so that the caregiver gets to rest with the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver.

The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?

A. Bring a penlight from the side of the client's face and briefly shine the light on the pupil.

B. Ask the client to gaze at a distant object and then at a test object.

C. Obtain a tuning fork and place it in the middle of the client's forehead.

D. Have the client stand twenty feet away from a Snellen chart.

**Choice B is correct.** To test for accommodation, the nurse should darken the room and ask the client to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 4 inches from the bridge of the client's nose. The pupils normally converge and accommodate by constricting when looking at close objects.

While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedure?

A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool.

B. The head of the bed flat with the patient lying on the unaffected side.

C. Prone position with both arms extended above the head.

D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.

**Choice A is correct.** The patient should be sitting up, leaning over a bedside table with arms rested, feet supported on the ground, or stool so the needle can be inserted appropriately. Usually, only sufficient fluid to lubricate the pleura is present in the pleural cavity. However, excessive fluid can accumulate as a result of injury, infection, or other pathology. In such a case of pleural effusion or pneumothorax, the physician may perform a thoracentesis to remove the excess fluid or air to ease breathing. Thoracentesis is also used to introduce chemotherapeutic drugs intrapleurally. The nurse assists the client in assuming a **position that allows easy access to the intercostal spaces**. Two different client-positioning options are used for the thoracentesis procedure. An **upright** position is the **most preferred** approach and it allows access to the posterior approach to thoracentesis. In **patients unable to sit up**, the **supine position** is preferred. The preferred upright position is usually a **sitting position with the arms above the head**, which spreads the ribs and enlarges the intercostal space. The client **leans slightly forward** resting the head over the pillow. To ensure that the needle is inserted below the fluid level when fluid is removed (or above any liquid if the air is to be removed), the physician will palpate and percuss the chest and select the specific site for insertion of the needle. A place on the **lower posterior chest** **is often used to remove fluid** and a section on the **upper anterior chest is used to remove air**.

A **chest x-ray** before the procedure helps to identify the best insertion site. In an anteroposterior view of chest x-ray, pleural effusions become visible as **blunting of the lateral costophrenic angle** at a volume of 150–200 mL. On a lateral view of chest x-ray, even 50 mL of fluid may be directed as blunting the posterior costophrenic angle.

The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which **priority** action?

A. Assess the client for pain

B. Assess the client's oxygen saturation

C. Assess the client with the Glasgow Coma Scale (GCS)

D. Assess the client's lung sounds

**Choice B is correct.** Assessing the client's oxygen saturation is essential because this client is demonstrating manifestations of hypoxia. Early signs of hypoxia include altered mental status and restlessness. Moderate sedation uses multiple medications, such as fentanyl and propofol, to achieve a state of altered consciousness, so procedures like shoulder reductions may be completed with very little pain. These medications are CNS depressants, and during the procedure, the client is often given supplemental oxygen. Post-procedurally, the nurse will monitor the client's vital signs very closely.

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?

A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.

B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.

C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.

D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.

**Choice A is correct.** For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support.