FUNDS WEEK 1 REVIEW

A.A.P.I.E

A - Assess

A - Analysis

P - Plan

I - Implement

E - Evaluate

SMART goals

S - specific

M - measurable

A - attainable

R - realistic

T - time frame. (long or short term)

Normal adult blood pressure

< 120/80

Elevated blood pressure

120-129 systolic

< 80 diastolic

Stage 1 hypertension

140-159 systolic

90-99 diastolic

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\[ pain and fever can increase BP \]

Stage 2 hypertension

>160/100

Hypertensive crisis

>180/120

How is hypertension diagnosed?

there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis.

Hypotension in adults

< 90/60

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\[hypoglycemia and HF can decrease BP\]

Falsely low BP measurements can occur due to

using a cuff that is too large, applying the cuff too loosely on the arm.

Falsely high BP measurements can occur due to

applying the cuff too tightly, not supporting the client’s arm, measuring the blood pressure within 30 minutes after a client has smoked or exercised, and using a cuff that is too small.

Orthostatic hypotension

a drop in systolic pressure of at least 20 mm Hg, or a drop in diastolic pressure of at least 10 mm Hg, within 1 minute after moving to a sitting or standing position, is indicative of orthostatic hypotension 

Orthostatic hypotension can be prevented by interventions such as

hydration, medication management, gradual position changes, wearing compression stockings, physical therapy, avoiding triggers, and safety precautions to prevent falls caused by decreased cardiac output.

If blood pressure cannot be taken on arms it can be taken on

thigh using popliteal artery; but BP is significantly higher than in the arm

“white coat syndrome”

a phenomenon whereby a client experiences anxiety and a subsequent increase in blood pressure when in the health care setting or in the presence of health care personnel 

extrinsic factors for blood pressure

external factors that a client can control to some extent include: weight, use of stimulants such as caffeine or nicotine, medications, sodium intake, stress, and activity level, anxiety or fear

intrinsic factors for blood pressure

those that are not modifiable, such as age, ethnicity, genetics, and natural hormonal variations

Normal/expected pulse rate in adults

60 - 100 bpm

Pulse rate values

Newborn (full term; birth to 28 days) -110 to 160/min

Infant (1 month to 1 year) - 90 to 160/min

Toddler (1 to 3 years) - 80 to 140/min

Preschooler (3 to 6 years) - 70 to 120/min

School-age (6 to 12 years)- 60 to 110/min

Adolescent (12 to 20 years) - 50 to 100/min

The pulse rate varies due to many factors like

body position, age, activity, health conditions, body temperature, and medications

With elevated temperature and exercise, the pulse will 

increase

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(pain also causes HR increase)

For people that are athletic or have an underactive thyroid gland, the pulse will 

decrease

The pacemaker of the heart is the 

sinoatrial node or S.A. node

tachycardia

pulse greater than 100 bpm in adults

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\[pain, medications, anxiety, exercise, caffeine, nicotine can cause tachycardia\]

bradycardia

pulse less than 60 bpm in adults

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s/s: dizziness, syncope, chest pain, shortness of air, fatigue, and confusion

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\[physically fit or athletic people have bradycardia, It is expected, as the heart pumps fewer times\]

Arrythmia

an irregular rhythm or a pulse rate outside of the expected reference range

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s/s: shortness of breath or dizziness

The heart rate that is heard and/or felt at the apex of the heart called 

Apical pulse

Apical pulse is located

at the fifth intercostal space on the left side of the client’s chest at the midclavicular line.

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(In children younger than 7 years, the apex of the heart is located at the fourth intercostal space to the left of the sternum)

pulse deficit

the numerical difference between the apical pulse and the radial pulse; indicates a decrease in ventricular contraction or peripheral perfusion.

A pulse deficit can be caused by

aortic rupture, coronary artery disease, or atrial fibrillation

Peripheral pulse sites include

temporal,carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses

Pulse ratings

0 = absent/non-palpable pulse

\+1 = weak/diminished pulse

\+2 = normal pulse

\+3 = increased/ strong pulse

\+4 = bounding pulse

normal body temperature for adults

96\.8 degrees F (36 degrees C) to 100.4 degrees F (38 degrees C)

thermoregulation

The body’s natural mechanism for balancing body temperature

(The body maintains a fairly constant temperature through shivering, sweating, vasoconstriction, and vasodilation)

hyperthermia

a condition characterized by an elevation in body temperature, a flushed face, diaphoresis, tachycardia, and the skin feels hot upon palpation 

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s/s: dizziness, weakness, thirst, and nausea.

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Interventions: moving the client to a cooler environment, removing excess blankets and clothing (only have one top sheet), applying cold packs to the neck, axillae, and groin, administering an antipyretic, medication as well as I.V. fluids to maintain hydration 

hypothermia

A decrease in core body temperature due to extended exposure to cold or the inability of the body to produce heat

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s/s: shivering, decreased motor skills, and impaired peripheral perfusion are early clinical manifestations, confusion, poor concentration, dilated pupils, and loss of consciousness can occur as it continues.

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interventions: Cardiac monitoring and emergency resuscitation equipment, blankets, warm IV fluids

5 different sites for measuring body temperature are:

oral, tympanic, temporal artery, axillary, and rectal

Normal/expected respiratory rate in adults

12-20 breaths per minute

Respiratory rates ranges

Newborn (full term; birth to 28 days) - 30 to 60/min

Infant (1 month to 1 year) - 25 to 30/min

Toddler (1 to 3 years) - 25 to 30/min

Preschooler (3 to 6 years) - 20 to 25/min

School-age (6 to 12 years) - 20 to 25/min

Adolescent (12 to 20 years) - 16 to 20/min

Adult (20 years and older) - 12 to 20/min

Eupnea

respiratory rate within the expected range 

Tachypnea

Respiratory rate that is higher than the expected reference range

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(patients can experience tachypnea with increased physical activity, pain, or anxiety, or when they have a respiratory infection, such as pneumonia or asthma)

Nursing interventions for tachypnea

tachypnea due to pain may be alleviated with administration of an analgesic, combined with a position change and application of ice or heat

tachypnea due to an exacerbation of asthma may be treated with a medication such as a bronchodilator and by maintaining the client in an upright position

Bradypnea

Respiratory rate that is lower than the expected reference range 

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s/s: dizziness, fatigue, weakness, confusion, and impaired coordination

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(can be caused by various alterations in body function, such as increased intracranial pressure, hypothyroidism, and shock. other causes include alcohol toxicity, use of opioids or sedatives, and morbid obesity)

infectious agent

organism like fungi, bacterium, virus, parasite

reservoir

the habitat where it lives, grows, reproduces, and replicates

Common modes of transmisson

Contact, droplet, and airborne

P.Q.R.S.T

P - precipitating

Q - quality

R - region

S - severity

T - timing

A nurse is discussing factors affecting blood pressure with an assistive personnel. Which of the following factors should the nurse identify as potential causes for an increase in a client’s blood pressure? (Select all that apply.)

A. Anxiety

B. Use of nicotine

C. Young adult age

D. Obesity

E. Fear

A. Anxiety

B. Use of nicotine

D. Obesity

E. Fear

A nurse is caring for a client who reports dizziness when standing up. The client’s blood pressure after lying supine for 15 minutes is 136/86 mm Hg in the left arm. Which of the following findings would indicate the client is experiencing orthostatic hypotension?

A. B/P 128/84 mm Hg, left arm, sitting for 2 minutes

B. B/P 120/78 mm Hg, left arm, immediately after sitting

C. B/P 114/72 mm Hg, left arm, immediately after standing

D. B/P 124/80 mm Hg, left arm, standing for 3 minutes

C. B/P 114/72 mm Hg, left arm, immediately after standing

A client reports a sharp, stabbing pain in the left leg that started suddenly after lifting a heavy object. This type of pain is best described as _____ pain.

acute

Clients with contagious, airborne diseases are commonly isolated in ________ pressure rooms as a method of infection control to some disease such as tuberculosis, measles, and SARS.

negative

Which is a known adverse effect of morphine sulfate? \n \n 1. Lessens pain.  \n 2. Respiratory depression.  \n 3. Vasoconstriction.

2. respiratory depression

An assistive personal staff member reports that a Client has the following vital signs. Which vital sign should the nurse check again? Temperature 100 °F, pulse 90 beats per minute, respiratory rate 19 breaths per minute, and blood pressure 86 over 56 millimeters of mercury (mmHg).

blood pressure

Vancomycin-resistant enterococci (V.R.E.) can be transmitted from one person to another through _______ with contaminated surfaces or equipment or through person to person spread, usually through contaminated hands. V.R.E. is not transmitted through the air by coughing or sneezing.

contact

Clients undergoing transplants and cellular therapy are at a greater risk for _________ when exposed to plants and flowers that contain fungal spores. Furthermore, when a plant wilts and dies, it can cause emotional distress.

infection

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rationale: Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (W.B.C.) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept such gifts into the room because they are at a greater risk for infection.

What is the most accurate type of blood pressure measurement for effective management of hypertension, especially for individuals with inconsistent readings using digital devices?

manual

A client is asking for pain medication. The nurse’s priority of action should be: \n \n 1. Ask the client to rate their pain level on the pain scale. \n 2. Provide the pain medication as needed. \n 3. Always provide non pharmacological interventions.

1. ask the client to rate their pain level on the pain scale

What is an appropriate nursing intervention for a client experiencing night sweats, weight loss, and pink tinged sputum? \n \n 1. Encourage the client to keep the door open for fresh air. \n 2. Advise the client to limit physical activities to reduce sweat production. \n 3. Emphasize the importance of keeping the door closed to prevent the spread of the disease. \n 4. Allow the client to eat meals with other clients in the communal dining

3\. Emphasize the importance of keeping the door closed to prevent the spread of the disease.

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Rationale: Emphasizing the importance of keeping the door closed to prevent the spread of the disease (Option 3) is the appropriate nursing intervention because tuberculosis is spread through airborne droplets and keeping the door closed helps to prevent the spread of the disease to others in the facility.

When the nurse is administering morphine to a client, the ___________ rate should be assessed first.

respiratory

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Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine the priority assessment is respiratory rate. Morphine can cause respiratory depression. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12 per minute.

A client's ____-______ of pain is the most reliable way of determining the severity of their pain.

self-report

John has been experiencing pain in his lower back for the past year. He has seen multiple healthcare providers, but the pain persists. John's persistent lower back pain is an example of _______ pain.

chronic

Cheyne-Stokes respiration is a type of abnormal breathing pattern characterized gradual increase and then gradual decrease in depth of respirations followed by periods of no breathing called _____.

apnea

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This type of breathing pattern can be seen in individuals with heart failure, stroke, or other neurological conditions, and it is often associated with changes in oxygen and carbon dioxide levels in the blood. Understanding the signs and symptoms of Cheyne-Stokes respiration is important for nurses and other healthcare professionals, as it can be an indicator of a serious underlying medical condition and may require intervention to maintain adequate oxygenation and prevent complications.

If it is not possible to place the pulse oximeter on the client's fingers or toes, which alternative body part should the nurse use to assess oxygen saturation?

earlobe

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The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.

A nurse is caring for a client who is recovering from abdominal surgery. His original discharge plan was moved because he developed fever and respiratory distress syndrome. The chest x-ray confirmed pneumonia. This infection is described as __________-__________ _________.

Healthcare-associated infection

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Healthcare-associated infections (HAIs) are infections that occur as a result of healthcare interventions and are not present at the time of admission to a healthcare facility.

Which intervention would be appropriate for a client experiencing tachypnea during an anxiety-induced panic attack?

1\. Providing supplemental oxygen through a nasal cannula or face mask. \n 2. Administering a bronchodilator medication to open up the airways. \n 3. Encouraging the client to breathe into a paper bag.

3\. Encouraging the client to breathe into a paper bag.

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rationale: To address tachypnea during an anxiety-induced panic attack, one intervention that can be helpful is to encourage the client to breathe into a paper bag (Option 3). Breathing into a paper bag can help increase carbon dioxide levels in the blood, which can help reduce symptoms of hyperventilation and tachypnea. This can also help the client feel more in control of their breathing, which can reduce anxiety and promote relaxation. Other interventions for panic attacks may include relaxation techniques, cognitive-behavioral therapy, and medication management. Providing supplemental oxygen (Option 1) isn't necessary as hyperventilation results in excess oxygen and decreased carbon dioxide. Administering a bronchodilator (Option 2) isn't appropriate as the issue here is not airway constriction, but rapid breathing due to anxiety.

A 3-year-old child has a staph skin infection. Which of the following will most likely cause transmission of the organism to his 5-year-old sister?  \n \n 1. Sharing the same bath towel.  \n 2. Coughing without covering his mouth.  \n 3. Goodnight kisses for her sister.

1. Sharing the same bath towel

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rationale:  Direct contact is the mode of transmission for staphylococcus. Touching surfaces that have been contaminated by a person can also spread infection. This is known as indirect contact. Sharing the same bath towel (Option 1) could easily transmit the infection to the 5-year-old sister as the towel can carry the bacteria from the infected skin. Staph is not spread by coughing (Option 2) nor oral secretions (Option 3) . They are not spread through the air. 

The nurse is caring for a client who is using an aquathermia pad. The nurse should stop applying the pads when the client’s skin gets ____________.

Erythematous (redness of skin)

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Rationale: Reactions such as unusual pain or redness are indications for removing the pad and notify the provider.

A 55 year old male client is receiving antihypertensive medication as prescribed. The nurse took the blood pressure before administering the medication and noticed the blood pressure is 89 over 65. The nurse's priority action is to ____ the medication and notify the provider.

hold

When caring for a client with Clostridium difficile infection, you should not use _______ based hand-rubs when exiting the room.

alcohol

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rationale: Alcohol-based hand rubs (A.B..H.Rs) are an effective means of decreasing the transmission of bacterial pathogens but it is not effective against Clostridium difficile spores. Hand washing with soap and water is significantly more effective at removing C. difficile spores from the hands than A.B.H.Rs.

A client taking oral contraceptives is being treated for a urinary tract infection with antibiotics. Which statement indicates that the client needs further explanation?  \n \n 1. “My husband and I are working on a second method of birth control.” \n 2. "I’ll make sure to keep the leftover pills out of my children’s reach."  \n 3. “I’ll avoid drinking any alcohol.”

2\. "I’ll make sure to keep the leftover pills out of my children’s reach." 

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Rationale: Antibiotics should be finished to prevent development of antibiotic resistance. It should be taken with meals or snacks to prevent stomach upset. The statement "I’ll make sure to keep the leftover pills out of my children’s reach" (Option 2) indicates misunderstanding because antibiotics need to be taken completely as prescribed, and there should not be "leftover" pills. A second method of birth control (Option 1) is recommended because antibiotics can potentially decrease the effectiveness of oral contraceptives. Avoiding alcohol (Option 3) is a good practice when taking antibiotics as alcohol can interact with certain antibiotics causing side effects and decreasing their efficacy.

A chinese client indicates that his back pain is not being relieved despite of frequent acupuncture sessions and chiropractor visits. X-ray reveals that the client has spinal cord impingement and would need spinal surgery to correct the pain. The client though hesitates and does not show interest of pursuing the procedure. The nurse understands that this hesitation is due to ________ norms about pain relief.

cultural

A client with chronic obstructive pulmonary disease (COPD) has been admitted to the hospital with worsening shortness of breath and a respiratory rate of 28 breaths per minute. The client is started on oxygen therapy via a non-rebreather mask at 12 liters per minute. After 30 minutes of therapy, the client's respiratory rate has decreased to 22 breaths per minute. This reflects a ________ outcome of the oxygen therapy.

positive

A client with a fever of 102 °F arrived at the clinic requesting an antibiotic prescription. What is the nurse's best response?  \n \n 1. "Take the antibiotics with a meal or snack." \n 2. "Once you start the antibiotics, make sure to finish the antibiotics even when your fever goes away." \n 3. "Fevers are not always caused by bacteria."

3. “fevers are not always caused by bacteria.”

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Rationale: Not all fever requires antibiotics because not all fever are bacterial in nature. Fever is a symptom not an illness. The nurse's best response in this situation is (Option 3): "Fevers are not always caused by bacteria." This response educates the client about the fact that fevers can be caused by various factors, including viral infections, which do not respond to antibiotics. Advising the client to take the antibiotics with a meal or snack (Option 1) assumes the client will receive antibiotics despite the unknown cause of the fever, which may not be appropriate. Emphasizing the importance of completing the antibiotics (Option 2) assumes that antibiotics are necessary and overlooks the need for proper diagnosis before prescribing antibiotics.

A client diagnosed with fibromyalgia is facing a situation where his pain is not well controlled by an opioid medication. What additional type of medication is often used in these situations to enhance the effects of the primary pain medication?

Adjuvant medications

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**Explanation:** An adjuvant (or co-analgesic) is a drug that in its pharmacological characteristic is not necessarily primarily identified as an analgesic in nature but that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when used with opioids.

Which isolation category requires the use of neutropenic precautions? \n \n 1. Contact isolation for a client with a wound infection caused by MRSA. \n 2. Airborne isolation for a client with active tuberculosis. \n 3. Droplet isolation for a client with pertussis. \n 4. Protective isolation for a client undergoing chemotherapy.

4\. Protective isolation for a client undergoing chemotherapy.

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**Explanation:** Neutropenic precautions are used for immunocompromised clients, such as those undergoing chemotherapy (Option 4), who are at high risk for infection due to low white blood cell counts. These precautions include the use of personal protective equipment (PPE), such as gowns, gloves, and masks, to prevent the transmission of microorganisms from healthcare workers and visitors to the client, as well as the restriction of visitors who have symptoms of illness. Contact isolation (Option 1) is for clients who have infections that can be spread by direct or indirect contact, not specifically requiring neutropenic precautions. Airborne isolation (Option 2) is used for clients with airborne infectious diseases like tuberculosis but does not require neutropenic precautions. Droplet isolation (Option 3) is utilized when dealing with diseases spread through droplets, such as pertussis, and does not require neutropenic precautions.

The pain scales that can be used by the nurse in determining an infant's level of pain is called _____.

F.L.A.C.C

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**Explanation:** FLACC is a pain assessment tool used to evaluate pain in clients who are unable to communicate their pain using traditional pain scales, such as infants and clients with cognitive impairment or neurological deficits. The acronym FLACC stands for "***Face, Legs, Activity, Cry, and Consolability".***

A client with cholecystitis complains of pain rating of 6 over 10. The nurse dims the lights, turns off the T.V., and suggests distractions like listening to relaxing music. What type of nursing interventions do these actions fall under? \n \n 1. Physiological interventions. \n 2. Educational interventions. \n 3. Environmental interventions. \n 4. Safety interventions.

3\. Environmental interventions.

The nurse accidentally punctured her skin while attempting to dispose of a used needle in a sharps container. The nurse should ____ the area of the puncture thoroughly with soap and water.

wash

A 26-year-old female client’s vital signs are the following: temperature of 97.7°F, blood pressure of 120 over 80 millimeters of mercury (mmHg), respiratory rate of 19 per minute, heart rate of 110 beats per minute, pain rating of 3 out of 10, and oxygen saturation of 98%. The nurse should further assess _____ ____ and pain.

heart rate

Which part of P.Q.R.S.T. assessment is represented by burning, aching, stabbing, and throbbing?

Q - quality

When taking the blood pressure, using a cuff that is too narrow leads to falsely ____ blood pressure readings.

high

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**Explanation:** The most common error when using indirect blood pressure measuring equipment is using an incorrectly sized cuff. A B.P. cuff that is too large will give falsely low readings, while an overly small cuff will provide readings that are falsely high.

A school nurse had just completed giving health teaching to a group of parents regarding pediculosis capitis. Which statement indicates an understanding of the teaching? \n \n 1. "I will check my dog at home and place him in the kennel." \n 2. "I will wash my linens with warm water." \n 3. "I will isolate some non-washable items in plastic bags." \n 4. "I will spray pesticides across the house including cabinets and drawers."

3. I will isolate some non-washable items in plastic bags

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**Explanation:** Head louses are a common parasitic infection for school children. For any non-washable items especially toys should be placed in sealed plastic bags (Option 3) for 7-14 days to prevent the proliferation of the louse. Head lice infest human hair and cannot be transferred to pets, so there is no need to check a dog or place it in a kennel (Option 1). Washing linens in warm water (Option 2) is not sufficient to kill lice and eggs; hot water (at least 130°F or 54.4°C) is recommended. Spraying pesticides throughout the house (Option 4) is unnecessary and can be harmful; lice do not infest homes like other pests.

A nurse is preparing to take the oral temperature. The nurse should come back after __ minutes to take the temperature when the client has consumed hot or cold liquids.

30

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**Explanation:** The oral temperature measurement increases after sustained chewing and stays elevated for up to 20 minutes, probably because of increased blood flow to the muscles of mastication. Drinking hot liquids also increases oral readings for 15 to 25 minutes, and smoking a cigarette increases oral readings for 30 minutes. Drinking ice water causes the oral reading to fall for about 10 to 15 minutes.

The nurse applies cold compresses to a client's sprained leg. Based on SMART goals principles, what indicates the 'Measurable' effectiveness of the intervention? \n \n 1. There is a marked decrease of the swelling. \n 2. Increase in the range of motion. \n 3. Pain rating decreased from 7 to 4. \n 4. Normal vital signs.

3\. Pain rating decreased from 7 to 4.

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**Explanation:** Application of cold temperature to a sprain injury relieves inflammation and in turn decreases the pain on the site. The main indication of the effectivity is decreased pain. (Option 3) provides a measurable and specific change in the client's condition, indicating the effectiveness of the intervention. Using a pain scale provides an objective measurement of pain reduction. (Option 1) and (Option 2) indicate improvement, but they are not as quantifiable or specific as Option 3, making them less measurable. (Option 4) is not directly relevant to the specific intervention of a cold compress for a sprained leg.

The nurse is about to leave the respiratory isolation unit and is removing the PPE. Which action would cause his charge nurse to intervene? \n \n 1. Removing the mask before any other PPE. \n 2. Removing the gloves first in an inside out fashion. \n 3. Washes the hands after removing everything. \n 4. Removes the goggles after removing the gloves.

1\. Removing the mask before any other PPE.

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**Explanation:** Removal of the PPE is as follows: 

1\. Gloves in an inside out manner. 

2\. Goggles and Face Shield. 

3\. Gown without touching the front side. 

4\. Mask after leaving the isolation area. 

5\. Handwashing.

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The mask (option 1) is the last piece of PPE to be removed, as it provides protection from airborne pathogens, so removing it before other PPE can increase the nurse's risk of exposure and needs the charge nurse to intervene. According to the standard sequence of removing personal protective equipment (PPE), gloves should be removed first (option 2) to minimize exposure to pathogens, followed by goggles (option 4), and then gown. Hand hygiene (option 3) is crucial and must be done after removing all PPE to ensure that any residual contamination is eliminated, making this the correct final step.

What is the best way to prevent hospital acquired pathogens from spreading? \n \n 1. Isolate clients who are infected. \n 2. Initiate bathing every morning at start of shift. \n 3. Adherence to feeding schedule. \n 4. Handwashing on multiple critical times in handling the client.

4\. Handwashing on multiple critical times in handling the client.

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**Explanation:** Handwashing (Option 4) is the best manner of preventing the spread of most infections. This practice is critical before and after client contact, and after contact with any potentially contaminated material. While isolation of infected clients (option 1) can help to prevent spread, it is not universally applicable since not all infections may be immediately apparent. Bathing clients (option 2) and adherence to feeding schedules (option 3) are important aspects of patient care but don't directly address prevention of pathogen spread.

How would a nurse assess the timing of a client's chest pain? \n \n 1. By asking the client about what makes the pain worse or better. \n 2. By asking the client about how the pain feels, like sharp, dull, or throbbing. \n 3. By asking the client about when the pain first started. \n 4. By asking the client about where the pain is located.

3\. By asking the client about when the pain first started.

How should the nurse best obtain the client's body temperature if a client with suspected COVID-19 came to the emergency department complaining of difficulty breathing? \n \n 1. Using an axillary thermometer. \n 2. Using a rectal thermometer. \n 3. Using a temporal thermometer. \n 4. Using an oral thermometer.

3\. Using a temporal (forehead) thermometer.

What is the appropriate action to take if you notice a student nurse is only wearing clean gloves before placing an indwelling foley catheter? \n \n 1. Continue with the procedure. \n 2. Start the procedure over with new sterile equipment. \n 3. Report the incident to a supervisor. \n 4. Change to a straight catheter insertion method.

2\. Start the procedure over with new sterile equipment.

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**Explanation:** Strict sterile technique or surgical asepsis (Option 2) is critical when inserting indwelling catheters to prevent the introduction of harmful pathogens to the client's urinary tract. Clean gloves (Option 1) do not provide an adequate barrier against these pathogens, so it is necessary to start over with a new sterile field and equipment to ensure client safety. Reporting the incident to a supervisor (option 3) is unnecessary in this context, and changing the insertion method (option 4) does not resolve the issue of breaking sterile technique.

What is the best location to auscultate a client's heart rate when verifying the apical pulse before administering digoxin? \n \n 1. Clavicular area. \n 2. 3rd intercostal space, right sternal border. \n 3. Left side, mid-clavicular line, fifth intercostal space. \n 4. 3rd intercostal space, left sternal border.

3\. Left side, mid-clavicular line, fifth intercostal space.

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**Explanation:** The apical pulse is located on the left side, mid-clavicular line, fifth intercostal space (Option 3). Verifying the apical pulse is important before administering medications such as digoxin, which affect the heart rate, to ensure that the medication is given safely and appropriately. Options 1, 2, and 4 represent different anatomical locations and do not align with the location of the apex of the heart and may lead to incorrect assessments of the heart rate.

When providing basic life support, which pulse is best to effectively evaluate circulation of an unconscious client? \n \n 1. Inguinal. \n 2. Brachial. \n 3. Carotid. \n 4. Dorsalis pedis pulse.

3. Cartoid

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**Explanation:** The carotid artery (Option 3) is the closest pulse to the heart and an indication of cardiac function, especially for unresponsive clients. The carotid pulse is the most accessible and reliable pulse to evaluate circulation in an unconscious client during basic life support. It is located on either side of the neck, next to the windpipe, and can be easily located by pressing lightly with the fingertips. The brachial pulse (option 2) is used primarily for infants during CPR, while the inguinal (option 1) and dorsalis pedis pulses (option 4) are peripheral and not typically used to assess circulation in an unconscious client during CPR.

What is the most effective statement a nurse can use to educate a client who says "Why would I need to be alone in this room, I could isolate myself at home"? \n   \n 1. "Isolation measures are important to prevent the spread of infection to other people." \n 2. "It's important to follow our hospital's policies and procedures for isolation." \n 3. "Being at home will not make you safe." \n 4. "Being in isolation in the hospital allows us to monitor you more closely and provide necessary treatments."

1. ‘Isolation measures are important to prevent the spread of infection to other people”

_____ is an early indicator of a systemic infection.

fever

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**Explanation:** An infection that affects the entire body rather than being localized to one particular area or organ is called systemic infection. Systemic infection creates an increase in WBC count and triggers the massive inflammatory response across the entire body sytem. Multiple cell receptors will then identify the causative microorganism and would push the body to increase its over-all temperature thus the development of fever.

A nurse noted that a client with methicillin-resistant staphylococcus aureus seems to be irritable since his isolation. Which action should the nurse take next?  \n \n 1. The isolation precaution for this client needs to be lifted.  \n 2. To divert the client's attention and feelings, invite more friends and family to visit him.  \n 3. Educate the client about reasons for isolation and provide meaningful stimulations.

3\. Educate the client about reasons for isolation and provide meaningful stimulations.

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**Explanation:** The psychological effects of being in an isolation room must be considered in your care of clients. Clients in isolation may develop a sense of loneliness or anger. This makes option 3 the best choice, as it involves both providing the client with an understanding of why isolation is necessary, and also mitigating the distress by ensuring the client is mentally stimulated and not feeling abandoned or isolated. Lifting the isolation precaution (Option 1) is not feasible as the isolation is necessary for infection control. Inviting more visitors (Option 2) is not advisable as it could increase the risk of spreading the infection to visitors.

What is the next step in post-exposure prophylaxis after washing the exposed area with soap and water following a needle stick injury? \n \n 1. Determine the HIV status of the source client and the exposed individual. \n 2. Initiate appropriate prophylaxis based on the type of exposure and the HIV status of the source client. \n 3. Provide counseling and follow-up testing as needed. \n 4. Report the injury immediately to a supervisor or occupational health service.

4\. Report the injury immediately to a supervisor or occupational health service.

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**Explanation:** The next step in post-exposure prophylaxis after washing the exposed area with soap and water is to report the injury (Option 4) immediately to a supervisor or occupational health service. This allows for prompt evaluation and management of the exposure, including determining the HIV status (Option 1) of the source client and the exposed individual, initiating appropriate prophylaxis (Option 2) based on the type of exposure and the HIV status of the source client, and providing counseling and follow-up testing as needed (Option 3). 

In discussing pain felt by elderly clients, the nurse is correct if she states the following: \n \n 1. "Their response to medication is faster compared to younger individuals". \n 2. "Stimulus toward pain is impaired due to the deterioration of nerve ending in the aging skin causing diminished sensation". \n 3. "Pain for elderly clients is more psychological than physical". \n 4. "Pain for both young and old are almost at the same level of intensity".

2\. "Stimulus toward pain is impaired due to the deterioration of nerve ending in the aging skin causing diminished sensation".

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**Explanation:** The aging process affects nerve endings, which can lead to impaired stimulus towards pain and diminished sensation in the skin (Option 2). Stating that the response to medication is faster in elderly clients (Option 1) is not accurate as medication response can vary among individuals regardless of age. Claiming that pain for elderly clients is more psychological than physical (Option 3) is a generalization and not supported by evidence. Suggesting that pain intensity is the same for both young and old (Option 4) overlooks the potential differences in pain perception and experience between different age groups. 

Which intervention is appropriate for a client with pain who is at risk for hepatotoxicity from acetaminophen? \n \n 1. Administer the maximum recommended dose of acetaminophen every 4 hours as needed. \n 2. Monitor liver function tests at baseline and periodically throughout treatment. \n 3. Discontinue acetaminophen only if the client experiences symptoms of liver damage.

2\. Monitor liver function tests at baseline and periodically throughout treatment.

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**Explanation:** Monitoring liver function tests at baseline and periodically throughout treatment (Option 2) is an appropriate intervention for a client with pain who is at risk for hepatotoxicity from acetaminophen. Acetaminophen can cause liver damage in high doses or in clients with pre-existing liver disease. Monitoring liver function tests can help detect any liver damage early on and allow for appropriate intervention.Administering the maximum dose of acetaminophen (Option 1) can increase the risk of hepatotoxicity, especially if the client is already at risk. Waiting for symptoms of liver damage to appear before discontinuing acetaminophen (Option 3) might be too late, as significant liver damage can occur before symptoms are evident.

A client complains of severe pain despite being on regular pain medication. What is the appropriate nursing action? \n \n 1. Increase the dose of the medication without further assessment. \n 2. Use an appropriate pain scale to assess the client's pain level.  \n 3. Ignore the complaint as it is a common side effect of the medication. \n 4. Tell the client to wait for the next scheduled dose.

2\. Use an appropriate pain scale to assess the client's pain level. 

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**Explanation:** Assessing the client's pain level (Option 2) is an important nursing action in response to a complaint of severe pain. Also review the current pain management plan. This includes evaluating the effectiveness of the current pain medication, considering other pain relief options, and assessing for any possible side effects or drug interactions. Increasing the dose without further assessment (Option 1) could result in an overdose or other complications. Ignoring the client's complaint (Option 3) is against nursing ethics and does not address the client's needs. Telling the client to wait for the next scheduled dose (Option 4) disregards the client's current discomfort and could lead to under-treatment of pain.

What is an example of an open-ended question a nurse could use to facilitate therapeutic communication with a client experiencing pain? \n \n 1. "Have you been experiencing any pain lately?" \n 2. "Do you want to talk about how you're feeling?" \n 3. "How has the pain been affecting your daily activities?" \n 4. "Are you taking any pain medication right now?"

3. “How has the pain been affecting your daily activities?”

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**Explanation:** "How has the pain been affecting your daily activities?" (Option 3) is an open-ended question that encourages the client to provide a more detailed response and express their feelings and concerns, which can help build trust and rapport between the nurse and the client. Options 1, 2, and 4 are closed-ended questions as they require a 'yes' or 'no' response.

Which statement indicates a need for clients under pain medication to be educated further on the effect of analgesics? \n \n 1. "I'm glad I only need to take pain medication when I'm really hurting." \n 2. "I will stop taking the medication once the pain subsides." \n 3. "I don't want to become addicted to pain medication." \n 4."I'll just take two pills instead of one to get faster relief."

4. “i will just take two pills instead of one to get faster relief.”

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**Explanation:** Taking two pills instead of one to get faster relief (Option 4) indicates the client's lack of understanding about the proper dosing of analgesics and the potential risks of overdosing. Overdosing on pain medication can cause serious side effects and potentially be life-threatening. Options 1 and 2 indicate an appropriate understanding of using pain medication as needed, while Option 3 indicates that the client understands the potential dependency associated with pain medication.