Nursing Process & Management of Care Prepared by Gregory Zilberman, RN BSN (2017)‘The nursing process is based on a nursing theory developed by Ida Jean Orlando, She developed this theory in the late 1950's as she observed nurses in action She saw "good" nursing and "bad" nursing, Ever since the hursing process is used by nurses every day to help patients improve their health and assist doctors in treating patients. ‘The process is based on nursing training and works as form of problem solving ‘The nursing process is made up ofa series of steps Assessment Evaluation Nursing Diagnosis iq, Nursing ® Process Citical Tending Planning Implementation ‘The nursing process can be stopped at any step as necessary or can be repeated as needed This process is inclusive of physical health as wel as the emotional aspects of patient health, Nursing knowledge is used throughout the process to formulate changes in the patient's concition. During the process, nurses use this knowledge to identify problems and changes that are occurring to the patient. Caring for a patient requires the nurse to communicate with the patient to determine how they are feeling and gain the results of implemented care from the patient. ™ Assessment of the patient's needs: * Collecting data: = Subjective (“symptoms” thatthe patient describes) = Objective (sins that can be observed, measured, and verified) Patient's present complains = Past medical history = Review of systems = Physical assessment = observation of voluntary and involuntary motor movement = Sensory and verbal cues = Laboratory data = Recording data"Nursing Diagnos ‘+ NANDA "North American Nursing Diagnosis Association” + NANDA-contain the following components Word or Phase about the degree or amount of change noted, indicated by following: Imbalanced Impaired Ineffective Intolerance Dysfunction Immediacy of the problem, indicated by: Risk for High risk for issue or system involved such as: Skin Pulmonary Cardiac Bowel Bladder Type of problem such as: injury Fracture Activity affected, such as: Mobility Coping Tissue perfusion Cause or etiology Related to- Priority listing ‘Most important first or most in need of corrective care listed first followed by those in descending order of importance. Use Maslow’s Hierarchy of Needs. A high priority (not always the highest) nursing diagnosis addresses the client's deficient knowledge related to the medical diagnosis, treatment, and self-care needs. Client teaching in these areas is an ongoing nursing activity as the client’s condition and needs changes. ‘The categories of nursing diagnosis consider the physical, social, emotional, cognitive, spiritual, cultural, and environmental sources. It focuses on the healthcare needs, while a medical diagnosis focused on the client’s disease,Examples of Nursing Diagnosis: Ineffective coping (major depression) Timpalred gas exchange related to bronchial oclusion Decreased cardiac output related to cardiogenic shock. Ineffective tissue perfusion related to renal failure. Risk for infection related to inflamed appendix. Imbalanced nutrition, less than body requirements Impaired skin integrity related to second degree burns Knowledge deficit related to diabetes mellitus, type 1 Interrupted family process related to absent caregiver Ineffective infant feeding pattern related to cleft palate Impaired physical mobility related to muscle weakness. Ineffective breathing pattern (pneumonia) Fluid volume deficit (shock) Nursing Diagnosis Nursing Intervention HHYSIOLOGICAL: Impaired skin integrity | — Cchange client's position every 2 hours(a2h) = Protect bony prominences with foam pad = Manage to increase circulation Fluid volume deficit = Measure intake/output (VO) = _Monitor electrolyte levels = Decreased cardiac = Monitor vital signs (V/5) output Assess for hypaea ar shock =_Weigh patient dally to detect fluid retention + Aeration in tissue = Monitor vital signs (V/S) perfusion = Respiratory rate (RA), ECG, ABGS = Monitor renal function = Monitor consciousness and neurologic status = Ineffective airway = Place client in Fowler's position (45°) clearance Postural drainage, and percussion every 4 hours (aah) = Ineffective breathing Assess chest pain frequently, medication as needed pattern (Pa) atelectasis — Deep-breathe every 4 hours (q4h) to prevent impaired gas exchange | ~ Monitor vita signs (75) ARGS, Hemoglobin (Hb), Hematocrit (Het) Check urine/sto0 for signs of internal bleeding ‘iteration in bowel = elimination: Avoid use of bed pan constipation Increase fluid and fiber intake Teach client to avoid habitual use of actives Alteration in bowel elimination: Diarrhea uid and elecrohe replacement Assess fr signs of dehydration ‘Alteration of urinary = Catheter ‘elimination ation: only necessary (termite) Kegel exercises to strengthen sphincter contolPSYCHOLOGICAL: + Fear, Anxiety Encourage client to express fears and emotions Assign same nurse to care for cent if possible = Involve client in planning care—sense of control, = Encourage client to express sadness and anger = Encourage client and family to reminisce =" Encourage emotional support: family, suppor groups Let client increase selfcare levels at their own pace Accept client's hallucinations or delusions (do not challenge or ridicule) ‘Dysfunctional grieving ‘+ Ineffective coping + Sensory-perceptual = Sensony-perceptual ‘Compensate for loss of hesring Vilion ete, by mereasing eficit other sensory stimul Orient cent to realty: sights, sounds Call lent by name; mention place, time and date frequently Have family provide dllent with favorite belongings or photos to promote a sense of continuity Remain calm and unhurried-reduce cents feeling of lack ‘ofcontral ~ Remove sharp objects, ass. Allow dient o express emotions in non-violent way ‘> Alteration in thought | process related to memory loss = Potential for violence) — SOCIAL: ‘© Social isolation ‘Spend time with client—increase trust + Encourage group activities Speak slowly and distinctly, in normal tone Reduce clients frustration: Allow plenty of time for response ‘© Ask simple questions that require “yes" or “no” as Do not pretend to understand if you don't > Impeired verbal ‘communication = Planning = Toaddress client problem according to priority. = Toiidentity client outcomes or goals ("The cient wil..") Implementation = Nursing interventions based on the needs established by the nursing lagnoses to achieve the planned outcomes, Includes everything the nurse does such as Teaching client how to maintain his health Administering medications and treatments ¥ Providing comfort and support to family Encouraging client to express his feelings ¥- Compensating fo clients inability to perform certain activities ¥ Documenting all care ("If it’s not documented, i's not done”)" Evaluation = Measures the effectiveness of nursing interventions = Establishes that goals have been met, need to be reassessed and adjusted, or identifies new patient responses, which need to be put through the steps of the nursing process. Communication + Therapeutic communication techniques = Silence = Open-ended questions —“Tell me about.., “And then..” = Reflecting—poraphrasing what the client has ust said. = Restoting—repeating what the client has sid using his words. For example: Client: "1 don't belong here” ‘Nurse: "You don't belong here?” _ = Empathy —"it must be dificult for you." = Confrontation—only used in extreme circumstances “Are you thinking of committing suicide?” = Concreteness with redirection—used to relaforce realy in mental heath cients (Fldon’t hear any voices. Please come and finish drawing.” - + Non- therapeutic communication techniques = Focusing on the nurse have a headache and tink you arebelng ai”) = Giving ah zi [think you should leave your husband”) = Changing the subject (Fknow you are in pain, butlook at what a nicedayitis”™ ‘| = Confronting ina hostile manner [Fleokat the mess youmade.” ‘| ‘= Slaming the cient [Frau got iabetes because you id wach your at aie = Asking the cient Why” = Avoid “Why” questions because they put the client on the defensive = Asking the client questions, which only require a Yes or No answer? — Rather than saying “Are you in pain?” say “How are you feeling? Or “Describe your pain.” = Making false promises orgving fale assurance = "You'll be just fine.” = Discouraging the client to become independent: = “take core of you." = Telling the client how to feel or not to feet = "Don't worry." or “Aren‘t you glad you got rd of that diseased gallbladder?”How do we write information in the patient's chart? ‘© Subjective data: = Chief complaint or other information the patient or family members tell you + Objective data: = Factual, measurable data, such as observable signs and symptoms, vital signs, or test values + Assessment data: = Conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses + Plan: = Strategy for relieving the patients problems, including short and long term actions Priority in Nursing Assessment A-Airways B-Breathing C-Circulation [Bs Rrown ian ceriy woman with dlabetes who has Been oo lo get out of bed for 2 days. She has a severe cough and has been unable to eat or drink | during this time. Upon admission, her laboratory values show the following: Electrolytes: Sodium (Na+) 156 (135-145 mEq/L) Potassium (K¥) 4 (3.5-5.0 mEq/L) Chloride (Cl) 115 (98-106 mE9/1) Arterial Blood Gases (ABGs): pH 7.30 (7.35-7.45) pCO2 40 (35-45mm Hg) p02 70 (80-100mmHig) HCO3- 20 (22-26mEq/L) Four-Step Guide to ABG Analysis | Is the pif normal, acidotic or alkalotic? Are the pCO2 or HCO3 abnormal? Which one appears to influence the pH? | both the pCO? and HCO3 are abnormal, the one which deviates most from the norm Is ‘most likely causing an abnormal pH Check the pO2. Is the patient hypoxic? ‘What would be the priority nursing assessment? IMs Brown is in metabolic acidosis. You need to assess her respirations and breathe sounds. ‘smelt her breath to see ifit has a fruity smell tot The blood glucose has to be checked Check urine for ketones. KAN 8Client’s Needs > Maslow’s Hierarchy of Needs > “Higher level can only be achieved when lower needs are met” i ‘Salcactataion pessoal south and slnst cm a = ateon needs 1 I Achieved at responsi, quan unity. fein chp, ork 00. te L ok Ste ade ] este, sey rt eit ly te | — eee x Biolog an Py totes needs cree, = Physical Assessment Inspection- use of eyes to gather data about cent = Respiratory system Musculoskeletal system Neurological system = Skin integrity = Emotional and mental status Auscultation- listening to sound produced by the organs of the body: = Heart = tunes = Neck = Abdomen tne StETHOSCOPE 2 G Sound characterized by Pith = Intensify = Quality = DurationSUCH Oe Pyar Mate € 8 mm Decubitus Ulcers (Pressure sores) \ BMusculoskeletal System = Stooped = Fetal position = Straight Mobility = Inbed = Balance = Ambulation = Range of mation Respiratory System Respirtions = Rate, regularity, depth Byspnes =" 508 (exertion, at rest) Cough = Frequency, dy, productive, sputum = Cola, consistency Nervous System ‘Mental status = Alert = Awake = Spontaneous eye opening = _ Responsive to vocal and physica stimul Oriented to = Person = Place = Time = Abit to communicate Senses yes = PERRLA = Pups = Equal = Round = Reactive to Light and Accommodation (which ‘means the ability ofthe eyes to focus on objects that are close up and faraway) = Drainage 20060 ee = Performance of ADL’s Circulatory System Pulse = strength = Regularity = Rate Blood pressure Skin color Extremities Capillary Rel Normal <3 seconds) Urinary System = Frequency = amount = color = Dysura = catty = Blood or sediment Reproductive System (Female) breasts assessment = Any drainage from nipples = disctoration = tums Vaginal assessment = Any discharge, amount, odor, character Reproductive System (Male) Testes = Lumps Peis = Discharge /drainage Amount and character of drainage 4Digestive System Appetite = Amount of solids/liquids consumed Belching Burping Intolerance to foods = Frequency = Amount = Consistency = Color = Diarrhea = Constipation = Incontinence = Flatus Eating Difficulties chewing or swallowing. ‘Nausea/vomiting Bowel elimination Range of Motion (ROM) Active Range of Motion (ROM) Ghent performs eerie without asstance = ent ith independent perfomance of AD, but wth ited mobil = Goaltstomantainorinerease muscle strength and prevent muscle atrophy Passive Range of Motion (ROM) a cent cannot actively move = cannot contract muscles = Goalistomaintan joie exity 6Pre-Operative Care Assessment = Stress/ responses = Diagnosis/Fears tion for surgery (Implementation) = Informed consent = Labtests = chest xray = EKG Skin prep = (Vfrequire to do shaving, do Immediately prior to surgery. Bowel prep wv ‘NPpo Pre-op meds, sedation, antibiotics Removal of dentures, jewelry, all polish Nutrition = Solid fod alowed 8-10 hous before procedure (depends on procedure) = Gear fluids allowed 4 hours before procedure (depends on procedure) = May need TPN or tube feedings pre-op. CComplementary/ Alternative Therapies Supplements shouldbe stopped near the time of surgery, may interact with anesthesia and coagulation function. = Ephedra = Echinacea = Ginkgo = Garlic = Ginseng = kava = Stlohn's wart iminate all dietary supplements at east 2t03, weeks before surgery Post-Operative Care 1+ PACU [Post-Anesthesia-Care-Unit), + Early ambulation reduces postoperative complications Nursing Assessment Monitor effect of anesthesia postinduction Full system assessment Neuropsychosocial: Stimulate patient post anesthesia Monitor level of consciousness (LOC) Cardiovascular: = Monitor vital signs = Q15minxa = 30min x2 Qt hour x2 (then 2s needed) ‘Monitor /O ‘Check potassium (K+) Respiratory: = Check breath sound = Turn, cough, and deep breathing to prevent atelectasis “= Remove of chest secretion: (unless ‘ontraindicated-brain, spinal, eye surgery) = Assess pain level (using verbal and visual scale), Offer pain medication PAIN ASSESSMENT TOOL 041234567890 13 16amc how to un ncaa spcoreter Hold mouthpiece nowt, exhale normaly {alps and inhale sowiy ad deeply, ep falls render elevated 2.3 second, etal and repeat z Gastrointestinal: ‘Check bowel sound in 4 quadrants for S ‘minutes (high-pitched sound is abnormal) Keep NPO until bowel sounds are present Goad mouth care while NPO [Antiemetic's for nausea and veriting ‘Check abdomen for distention Check for passage of fiatus and stool Genitourinary Moritor!and 0 Encourage to void "Notify physician if unable to void within hours Catheterte if needed ols Catheter Insertion Get out of bed as soon as possible (heck pulses Assess color, edema, and temperature Inform patient not to cross legs ‘Apply antiembolie stockings (TED hose} before getting cut of bed Pneumatic compression devices "Monitor for Homan’ssign (pain with dorsiflexion of fot poste for DVT) ay vC Wound care Dcesing: eDocument amount and character of drainage = Physician changes first post-op dressing = Use aseptic technique = Note presence of drains Incision: = Assess site (edematous, inflamed, excoriated) — Assess drainage (serous, serosanguineous, purulent) = Note type of sutures (Absorbable and non absorbable) Note if edges of wound are well ‘approximated = Anticipate infection 3-5 days post-op = Debride wound, f needed, to reduce inflammation = Change dressing frequently to prevent skin breakdown around site Drains: Prevent fluids from accumulating in tissues Penrose drain Potential Post-op Complications ‘Complication ‘Assessment ‘Nursing Consideration Temorthage TF Replace Bd ele 1Puse Sotontorv/s a. damm kn Shoe 1 rere Tse toneen (Cae day shin sites Telesis and preumonia | renee Can be experienced on Tay poroP {ue ‘Postural drainage Tachyaria Sanubiotes Heated Cong and rn Patnon fected side : Tnbolm ‘Dyspne Canon aay POP Hemoptsis ‘Anteongotot hepa) ‘ASG Ob nd igh C2 sw ees Dezpvein tromboais Poste Ha sCanexpereneed 1A dnysup w LyeParacas ‘ive ‘Decompreson aber Tnfetion of wound vated Wa and ‘May oar in aye poop Peetive cure ‘aotee ‘Asepetectnique Sood nttion Dehineenee ‘Dipion of srg naan or wound + May ocrurn Seay PaLOp ‘he coughing sro 4 Not physian ‘visceration ‘Low Fowler postion ‘ho coughing Po {Cover viscera with tr sn dressing wa fou phsieon Urinary retention Toate va aE Bladder diatrsion May aur 8-12 Ws ponop ‘cathtarin a needed Trinary iafeion TH) Fouling wine ‘iy occur 58 day Oe Op Blvted Wat ‘eotie Payehows Trappropratenea ‘Therapeutic communeton Medison 19SPECIAL CONSIDERATIONS FoR ELDERLY CLIENTS, eo BR a ToLerance To MEDS (CPrevenrr over Separion) IV RATE To AVOID CHE 4 RISK OF: +ReSPIRATORY Deeression //7 * PNEUMONIA SDISORIENTATION [7p * SKIN BREAK DOWN 2 + PROBLEMS WITH: GP) KS NUTeITION Const) PATION 21) BALANCE AND 1 FAUS $ECUNICAL MANAGEMENTS Supden T Conrvsion V/ FOR URINE INFECTION FOR BYPOXIA FoR: ELECTROLYTE IMBALANCE TREAT COEXISTING MEDICAL DISORDERS, CARDIAC PROBLEMS PERIPHERAL VASCULAR DISEASE NEUROLOGIC DISORDERSNURSING DELEGATION AS A MANAGEMENT OF CARE + "Delegation is defined a the transfer of responsibilty forthe performance of task from one person to another” + “Transferring to a competent indvidval the authority to perform a selected nursing task ina selected nursing situation + Thenurse retains acountabity for deegation* 5 Rights to delegation + National Council of State Board of Nursing in the US presented 5 rights to delegation from the perspectives of both nursing service administrator and staff nurse, + Staff nurse is responsible for: Assessing client ¥ Delegating appropriately ¥ Communicate clearly Providing monitoring and supervision. Rule #1: + Donot delegate the functions of assessment, evaluation and nursing judgment. You learned that ‘assessment, evaluation and nursing judgment are the responsibilty ofthe registered professional ‘nurse, You cannot give this responsibility to someone else Rule #2: + This isnot the real world. Do not make decisions regarding management of care issues based on decisions you may have observed during your clinical experience in the hospital or clinic setting. Remember, the NCLEX is a perfect hospital. Rule #3: * Delegate activities for stable patients with predictable outcomes. Ifthe patient is unstable, or the ‘outcome of an activity nat assured, it should not be delegated. Rule #4: + Delegate activities that involve standard, unchanged procedures. Activities that frequently reoccur in daily patient care can be delegated. Bathing, feeding, dressing and transferring patient are examples, Activities that are complex or complicated should not be delegated. Rule #5: + Remember Priorities! Remember Maslow, the ABC's, and stable versus unstable when determining ‘which patient the RN should attend to fist. Keep in mind that you can see only one patient or perform fone activity when answering questions that require you to establish priorities. 2RN + Anything that deals with nursing judgment + Assessments + Teaching. | LPN/LVN + Can do dressing changes * Can be assigned to the UAP } Unlicensed Assisted Personnel most stable patient with the * Can do ADL's most predictableoutcome | + Ambulating i *CanalsopassPOmeds | + Bathing | + Feeding (as long as it’s a stable pt) + Turning ‘ollection urine, input and output. 2ROOM ASSIGNMENTS Nurses are responsible for identifying appropriate room placement for clients when they are being acimitted to the hospital. The goal is decrease the “RISK” of complications from this process. Nurses and students have requested that we develop a technique to assist in ‘organizing this process. “RISK” will assist you in organizing these placements Ifa client has internal radiation such as a radium implant, then the client should be placed in isolation to prevent injury to other dents. Acdlient with an infection or who is immunocompromised should be placed in appropriate isolation. Ifa client has tuberculosis, varicella, or measles then airborne transmission-based precautions are important to initiate and follow. Ifa client has neisseria meningitis, mycoplasma pneumonia, streptococcal group A infections, or pertussis then itis {important to follow droplet transmission-based precautions. Clients ‘with easily transmitted infections by direct contact such as gastrointes- tinal, respiratory, skin, or wound should be placed in a private room and have contact transmission based precautions initiated. Ifa client is immunocompromised (.e, from chemotherapy, in preparation for ‘a organ transplant, etc), then itis important to protect the client from infections. The main point to remember is to consider infection with the selection of zoomunates fora client Ifa client doesn’t have radiation (internal) or is not infected, then pethaps a major concem is with safety. Never place a combative or manic client with a depressed client or a client they could injure. If = client is at high risk for seizures due to pregnancy induced hyperten- sion, then the client's zoom placement is going to be very important 0 there is nota lot of stimulation in the environment. Another consider- ation when placing clients in a room isthe gender or sex of the client. {fnone of the above issues are concerns for the client and the client isa child, then knowing growth and development is important to consider when placing the child with a roommate. For example, ifa 6 year-old child has a fractured femur and there is another 6 year-old with a fracture or a post-op procedure with no infection, then this would be the best room placement due to the growth and developmen- tal needs, If however, there is another 6 year-old but the child has an infection, this would not be an appropriate zoomunate forthe child due to the risk of transmitting the infection. In review “RISK” will assist you in remembering how to select room assignments for dents 2[RReciation nfection/isolation S afety, sex Brow growth and development‘Standard Precautions: Key Components Handwashing (or using an antiseptic handrub) ‘+ After touching blood, body Muids, secretions, excretions and contaminated items ‘+ Immediately after removing gloves ‘= Between patient contact Gloves ‘+ For contact with blood, body fluids, secretions and contaminated items + For contact with mucous membranes and noniatact skin Masks, goggles, face masks Protect mucous membranes of eyes, nose and mouth when contact with blood and body fluids is likely Gowns ‘+ Protect skin from blood or body Nuid contact + Provent soiling of clothing during procedures that may involve contact with blood ‘or body Muids Handle soiled linen to prevent touching skin or mucous membranes Do nol pre-rnse soiled linens in patienl care areas Patient care eq Handle soiled equipment in a miaunes to prevent contact with skin or mucous ‘membranes and to prevent contamination of elothing or the environment + Clean reusable equipment prior to reuse Environmental cleaning ‘+ Routinely care, clean and disinfect equipment and furnishings in paticnt care arcas ‘Sharps + Avoid recapping used needles ‘+ Avoid removing used needles from disposable syringes ‘+ Avoid bending, breaking or manipulating used needles by hand ‘Place used sharps in puncture-resistant containers Patient resuscitation ‘+ Use mouthpieces, resuscitation bags or other ventilation devices to avoid mouth-to- mouth resuscitation int placement ‘= Place patients who contaminate the environment or cannot maintain appropriate hygiene in private roomsDISASTER PLAN ‘A disaster plan needs to be activated when there is life threatening sak and a lagge number of cients must be evacuated from the hospital, assisted living units ete. “MERRY” needs a way to remember which ‘lients to remove fret fom the rooms. ABC will assist in organizing this information! A AMBULATORY-The priotty isto evacuate the largest volume of, ‘lionts intially. B BED RIDDEN-The bed ridden cients will be the next group to be ‘evacuated from the rooms, Actually, the ambulatory group may bbe able to assist in getting this group evacuated more quickly. C CRITICAL CARE-The last group of clients to be evacuated will be the exitially il “The ultimate objcetive ina disaster plan isto evacuate volumes of clients. fhe clients with numerous tubes and IVs are evacuated initially this will slow the process down. Fever clients will be safely rescued from the disaster. 26TRIAGE T rouma RR espiratory/cardiac pce A\ ninfection G' E |imination [Nurses are quired to "TRIAGE" clients in the emergency depart- ment, ducing a disaster or at the scene ofa wauma. “TRIAGE” is Setting prlories for care based on the clients ability to survive with adequate intervention. (Clients involved in a trauma will be evaluated intially. The priority conceme with these clients include the 45's (Breathing, Bleeding, Broken Bones, Burns) Clients expe hypoxia fom alteration in {te respiatoryfcardiae system should also be Wiaged If the medieal condition is dwonic, however, andthe client presents to the clini for a routine visit, then tis cient would not be a priori ICP—Clients that present with head trauma, alterations inthe level of consciousness, or merous head and facial abrasions and lacerations, ust be evaluated quill. AN INFECTION—Clients that present tothe emergency department ‘with a severe infection may proceed to go into septic hock. Gl—Clients presenting with a Gr bleed must be tlaged. The client may, present with a history of taking NSAIDS or steroids. The client usually, ‘Presents with epigastric pain characterized ap being sudden, severe, [and diffuse. Stole and nasogastric drainage may have blood present. ‘The sbdomen may be distended. Vital signs wil change in correlation ‘with overall condition. ELIMINATION— Cents presenting with problems voiding or signs of pyelonephritis should be tiaged. ‘Note: Remember, client who has fred an dilated pupils, not breathing ana hear! rte present wil ot be triaged! 2‘Therapeutic Meal Plans Espo chew ad sulow Diet Purpose/Use. Foods Allowed Foods Restricted er “Tabepnfeodinroacion | Alor inuts lk rau, ke we Sy SO terremovl NG tube or feos tau Faia ‘Some aoe Boy ed aT | yao worm To poges deta, Soe tender onde ante | ighseasoned ood whol pains Tals esters es foods. ew fecal Sof tooss at nn Sew Bandit To prove ston oT sfter surgery, peptic, Intarmatory aes i ctr aes cel eae 05, ake or red potatos, Tigi seasoned svar oo, tes cafe col hae gras a cs Towa Bat Te dere far or Rolie “Sveti, daha ser Gear bats, ments es ttn cre tite esd pose te | rsa ihrbobarater ood Tapas wel gran, ‘es Tre FORBT Topreventaatect ot Tae haan oo ing was eres rtenton fs pecy inch fechas equals hanaine an eset | foul, noteeaetes, | andy prods Ses, fecad hidrencanrat | vegeta, ots faces. my ronionin program footy woh al Toa aan Gialaneat | Toprever atest [Lowat Ties mil, | eyo whole mi Fea ood, levels, reduced amount of red mest. ‘malabsorption of fat Tow aan aE Torah soianinnta | Se preparation food | Prowssed ond, smolador aed meas, Te Faas Bee orepsce om acne Sacer dita Died ata rates ash fre oaaran spre, ranges tomatoe Teno Conolpotetun, am, | Hghoiopal pote protein eve Cintas, | Near cone Proaucte ana decressed Penn chars Tan OT To dereaea Taf UieSG | Vettes, rts creas, | Gnd and ganesh POU, gs at cotagechowrs_| nt osmeal whole gras. Diabetic Di Tdieation| Diabetes melitus Purpose “To control plasma glucose evel Principles Each meal should conlain carbohydrates, ft and protein ‘vod skipping or delaying meals Frequent, small meals may gve better glucose control. Unplanned actvty- add snack to avoid hypoghcemis, 8High-protein Diet Indication Under nutrition [ise : Burns Purpose: "To support protein synthesis Encourage saat Meat, fsh, dairy products Extensive tissue repair may require upto 6,000 kcal/day. Vitamins: Souree Deficiency causes a ver Poor night vsion Eeeyolk ‘Growth retardation children) carrots D ‘ilk Bone deformities Sunshine in chldren rickets sin adult osteomalacia E Vegetable as Rare deficiency K tiver Bleeding disorders (defcency oF Egos coagulation factors) ___| Green ieaty vegetable € irs fruits Scary Roath oss, inpared ‘wound healing) Bi Tier, meat Peripheral neuropathy. _Werncke-Korsakot' (alcoholics), B2 Tver meat inflammation of tongue and lips (goss, chlo) c Biz Ter meat “Anemia, neuropathy iyooaerai ‘Anemia ++ Catelum, vitamin D, ‘Vitemin 8-12 ‘Supplements Fate, ols and sweets ‘use Sparinghy lg Ti, Gneese Group Water 6 ServingsAcquiring Cultural Competence Consider body language: + Eye contact + Touching + Personal space + Privacy/modesty Other cultural factors to consider: + Gender + Wealth or social status + Presence of a disability + Sexual orientation seine diffevent 's NOT A PROBLEM BEING TREATED DIFFERENTLY IS STOP DISCRIMINATIONSTRATEGIES FOR NCLEX EXAM Read questions and answers at least 3 times ANSWERS THAT INCLUDE GLOBAL WORDS SUCH AS THESE: always all Everyone Never None Only Every Must ‘should be viewed with caution; because they imply that there are no exceptions “There are very few instances In which a correct answer is that absolute ssasascce “nurse is providing Safety Instruction tothe mother ofa child with hemophilia and tells the mather to do ‘Which of the following to promote a safe environment forthe child? 1. Remove toys with sharp edges from the child's toy box. 2. Allow the child to play with toys only ia parent is present 3. Place ahelmet and elbow pads on the child every day. 4. Allow the child to play indoors only Answer: 1 Eliminate options that contain absolute words, Options 2 and 4 contain the absolute word only, Option 3 contains the absolute word every. Remember that absolute words tend to make an option incorrect © LOOK FOR THE UMBRELLA OPTION When answering 2 question, if you note that more than one option appears to be correct, look for the ‘umbrella option (also known as global option or comprehensive option). The umbrella option is one that is general statement and may contain the ideas of the other options within it The umbrella option willbe the correct answer. “murse From the emergency room receives telephone call from the emergency medical services and sold that several victims who survived a plane crash and are suffering fom col exposure wil be transported tothe hospital. The intial hursing action of the emergency nurse is which of the folowing? 1. Supply the trauma room with bottles of sterile water and normal saline. 2. all the laundry department and askthe department to send as many warm Blankets as posible tothe ‘emergency room. 3, Call the nursing supervisor to activate the agency dsater plan, 4. all the intensive care unit to request that nurses be sent tothe emergency room, Answer:3 ‘tivatng the agency disaster plan wil ensure that the Interventions in options 2,2, and wil occur. Remember the ‘umbrella option embraces the ideas ofthe other options within. a© ELIMINATING SIMILAR OPTIONS When answering the questions, use the process of elimination and look for similar options. ¥ ifany ofthe options include the same idea, then they are incorrect and can be eliminated, ¥- Remember that there is only one correct option and the answer tothe question i the option that is. different. = ‘Anurse is assigned to care for a group of clients’ medical records, the nurse determines that which client is at risk fr excess fluid volume? 1. The client with ileostomy 2. Theclient taking diuretics | 3. The client who requires gastrointestinal suctioning 4, The client with renal failure Answer: 4 Test ~ Taking Strategy: Focus on what the question is asking: the client at risk for excess fluid volume. Think about the pathophysiology associated with each condition identified in the options. The ony cient that retain fluid i the client with renal fallure. The client with an ileostomy, the client taking diuretics, and the L client requiring gastrointestinal suctioning all lose fluid, Remember eliminate similar options. _ USE OF NURSING PROCESS TO PRIORITIZE Y Assessment = Remember that assessment isthe first step in nursing process. = When you are asked to select your first and initial nursing action, follow the steps of ‘the nursing process to prioritize when selecting the correct option. = Aseezement questions address the process of gathering subjective and objective data relative to the client, confirming that data and communicating and documenting the data. = Look for key words in the options that reflect assessment, = Assessment Key Word: Determine Find out Identify Monitor Observe ‘Obtain information 2“A nurse is teaching a cient with coronary artery disease about dietary measures to follow. During the session, the client expresses frustration in learning the dletary regimen. The nurse would inital 1, Identify the cause ofthe frustration 2. Continue with the dietary teaching 3. Notify he physician 4, Tellthe client that the diet needs to be followed ‘Answer: 1 ‘Test-Taking Strategy: Use the steps of the nursing process. Assessment is the first step. Of the four options presented, the only assessment action i option 1. Options 2, 3, and 4 identify the implementation step of the ‘nursing process. The initial action isto identify the cause ofthe frustration, Remember assessment isthe fist step of the nursing process. Y Analysis “Aura is reviewing the laboratory results ofan infant suspected of having Hypertrophic pyore stenosis. Which ofthe fallowing laboratory findings would the nurse mos likly to expect to note inthis infant? 1. Ablood pit of 7.50 2. Ablood pH of 7.30 3. Ablood bicarbonate (HCOS) of 22 még/L 44. blood bicarbonate (HCO3) of 19 méa/L Answer: TestcTaking Strategy: An understanding ofthe physiology associated with hypertrophic pyloric stenosis and that ‘metabolic alkalosis kel to occur as result of vomiting is necessary. Next, the nurse must know which laboratory Findings would be noted in this acid base condition. Analysis of thie data will direct you tothe corret option Remember analysis is the second step ofthe nursing process. ‘nurse is teaching a client with coronary artery disease about detary measures to follow. During the session, the client expresses frustration i learning the dietary regimen. The nurse would intialy 1. Identify the cause ofthe frustration 2. Continue with the dietary teaching 3. Notify the physician 4, Tel the client that the diet needs to be followed. Answer: Test-Taking Strategy: Use the steps ofthe nursing process Assessment isthe ist step. Of the four options presented, the only assessment action option 1. Options 2,3, and ident the implementation step ofthe nursing process. The initia action sto identify the cause of the frustration, Remember assessment is the fist step of the nursing process 3Y Planning ~ Planning questions require priorting nursing diagnoses, determining goals and outcome criteria for {goals of care, developing the plan of care, and communicating and documenting the plan of car. ~ Regarding nursing diagnoses, remember that actual dient problems rather than potential or at-risk client problems will most likely be the priority = Remember that ths isa nursing examination and the answer tothe question most likey involves something thats included in the nursing care pian, rather than the medical “A nurse develops a plan of care for a client with a cataract. Which nursing diagnosis isthe priority? 1. Fear related to loss of eyesight 2. Socal isolation related to decreased ability to mobilize in the community 3. Disturbed sensory Perception (Visual) related to ocular lens opacity 4, Risk for injury related to decreased vision Answer: 3 ‘This question relates to planning nursing care and asks you to identify the priority nursing diagnosis, Use ‘Maslow’s hierarchy of needs theory to answer the question. Remembering that physiological needs are the priority will direct you to option 3. Although Risk for Injury is @ potential rather than an actual problem, according to Maslow’s hierarchy of needs theory, safety is the second priority. Fear and social Lisolation are psychosocial needs. Remember planning isthe third step of the nursing process. _] ¥ Implementation Implementation questions address the process of organizing and managing care, counseling and teaching, providing care to achieve established goals, supervising and coordinating care, and communicating and documenting nursing interventions. = This examination is about nursing, 20 focus on the nursing action ather than on the medial action; unless the question is asking you what prescription (medical order) is anticipated. ~The only client whom you need to be concerned isthe client in the question that you are answering; remember that this cient is your only assigned client. 7 nurse i caring fora cnt with angina pectoris who begins to experience chest pain. The nurse administers sublingual nitroglycerin (Nitrostt) tablet sublingual as prescribed, but the pain is unelieved. The nurse should take which ofthe following actions next? 4. Contact the physician 2. callthe client's family 3. Administer another nitroglycerin tablet 44. Reposition the client, | Answer:3 Implementation questions address the proces of organizing and managing are. This question alo requires that you priortize the nursing actions, Nate thatthe keyword next. Recalling thatthe nurse would administer three ‘itroglyerin tablets S minutes apart from each ather to relieve chest pain will asist in directing you to option 3 ‘Remember implementation is the fourth tep ofthe nursing process2 3) 4) y a a a 4) 2) 3 4) Review Questions ‘Apatient ares at the emergency department ‘complaining of mid-sternal chest pain. Which ofthe following nursing ction should tke priority? ‘Acomplete history with emphasis on preceding An electrocariogram, Careful assessment of vital signs. ‘Chest exam with auscultation Apatient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions toa patient and his family. Which ‘misunderstanding by the family indicates the ‘eed for more detailed information? The patient may esume normal home activites as tolerated but should avoid physical exertion and get adequate rest. ‘The patient should resume anormal diet with ‘emphasis on nutritious healthy foods. ‘The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved ‘The patient should continue use ofthe Incentive spirometer to keep airways open and {tee of secretions. ‘A nurse scaring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members aren the room around the clock performing unusual rituals and bringing ethnic foods. Which ofthe fllowing saetions should the nurse take? Restrict visting hours and ask the fami to limit vistors totwo at atime Notify sitors witha signon the door that the patient is limited to clear fui anly with no slid food allowed. It possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. Contact the physician to report the unusual rituals and activites, 4, ‘The charge nurse onthe cardiac unit is planning assignments forthe day. Which of the followings the most appropriate assignment forthe float nurse that has been reassigned from labor and delivery? 1) one-week postoperative coronary bypass patient, whois belng evaluated for placement of a pacemaker prior to discharge 2}. Rsuspected myocardial infarction patient on telemetry just admitted from the Emergency Department and schedule for an angiogram. 3) A patient with unstable angina being closely ‘monitored for pain and medication titration, 4). Apost-operative valve replacement patient ‘who was recently admitted tothe unit because allsurgcal beds were filed 5. Anewy diagnosed 8.year-old child with type iiabetes metus and his mother are recelving diabetes education prir to discharge. The ‘physician has prescribed Glucagon for ofthis mediation. Which of the following statements by the nurse is correct? 1). Glucagon enhances the effect of insulin in case ‘the Blood sugar remains high one hour after injection ‘Glueagon treats hypoglycemia resulting from Insulin overdose. {Glucagon treats lpoatrophy from insulin 4) Glucagon prolongs the effect of insulin, allowing fewer injections. 2 3) 66. Appatient onthe cardiac telemetry unit unexpectedly goes into ventricular fibrillation ‘The advanced cardiac ie support team prepares to defibrillate. Which of the following Choices indicates the correct placement ofthe conductive ge pads? 4) The lft clavicle and right lower sternum, 2} Right of midline below the bottom rib and the left shoulder. 3) The upper and lower halves ofthe sternum. 44) The right side ofthe sternum just below the lavile and left ofthe precordium, 36Y Evaluation Evaluation questions focus on comparing the actual outcomes of care with the expected outcomes and focus on how the nurse should monitar or make 2 judgment conceringa client's response to therapy orto a nursing ‘These questions address evaluating the cents ability to implement care, and the process of communicating and documenting evaluation findings. Inan evaluation question, be alert to false response question because they are used frequently in evaluation type questions, and the question may ask for a lent statement that indicates accurate or inaccurate Information related tothe issue ofthe question. “Relient with multiple slersis has been taking oxybutyni (Diropan). The nurse determines the degree ofthe tfectiveness of the medication by asking the client about changes i the following 4, Extent of muscle spasm 2. Level of fatigue 3. Bowel movements 4. Patterns of urination Answer: 4 This is an evaluation question, Note the keywords determine the degree of effectiveness, Oxybutynin is an antispasmodic used to veleve symptoms of urinary urgency, Frequency, nocturia, and incontinence in cents with Uninhibited or reflex neurogenic blader. Recaling that this medication is used to treat blade dysunction will rect you to option 4. Remember evaluation ithe fifth step ofthe nursing process ¥ THE ABC IN PRIORITIZATION = Use the ABCS~ airway, breathing, and circulation ~ when selecting an answer or determining the order of priority. — Remember the order of priority: airway, breathing, and circulation. = _Airway i always the first priority. “The client witha diagnose of cancer ie receiving @ morphine sulphate 10 mg subcutaneously every 3-4 Fours for pain. When preparing the plan of ere forthe cent, the nutse icles whic priority ation? 1. Monitor stools 2. Monitor the urine output 3. Encourage the client to cough and deep breath 4. Encourage fluid intake. Answer se the ABCS ~ airway, breathing, and circulation ~ asa guide to direct you tothe correct option. Recall that ‘morphine sulphate suppresses the couh reflex andthe respiratory reflex Although, options 1,2, and 4 are ‘components ofthe plan of care the correct option addresses airway. Remember use the ABCs airway, breathing, and circulation to priortize 35y 2 3) 4 0 a 3) a a) 2 3) 4) 20. v 2) 3) 4 1. The nurse performs an intial abdominal assessment on a patient newly admitted for ‘abdominal pain. The nurse hears what she ‘describes 2: "licks and gurgles in all four ‘quadrant as well 9 "swishing or buzzing sound heard in one or two quadants.” Which (ofthe following statements is correct? ‘The frequency and intensity of bowel sounds varies depending on the phase of digestion. Inthe presence of intestinal obstruction, bowel sounds wll be louder and higher pitched. ‘A suishing or buzzing sound may represent the turbulent blood flow ofa brut and snot rormal Allof the above [A patient arives in the emergency department ‘and reports splashing concentrated household «leaner in his ee. Which ofthe follwing hursing actions isa priority? Ieigate the eye repeatedly with normal saline solution. Piace fluorescein drops in the eve Patch the eye Test visual acalty ‘Anurses caring fora patient wh has had hip replacement. The nurse should be most concerned about which of the following findings? Complaints of pain during repostioning. Seant bloody discharge on the surgical dressing. Complaints of pain follwing physical therapy. Temperature of 101.8 (38.7) ‘A child is admitted tothe hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions tobe taken inthe event of a seizure. Which of the following actions would NOT be included? Notify the physician. Restrain the patents limbs. Position the patient on his/her side with the hea flexed forward ‘Administer rectal dazepam. a. 2 3 2 a 2) 3) 4 a. a 2) 3) 4) y 2 3) 4 Emergency department triage san important nursing function. A nurse working the evening shifts presented with four patients atthe same time, Which ofthe following patients should be assigned the highest priority? ‘Apatint with lowrerade fever, headache, and ‘myalgia forthe past 72 hours patient who Is unable to bear weight onthe left foot, with swelling and bruising following 2 running aecdent. patient with abdominal and chest pain {allowing a large, sicy meal ‘child with a one-inch bleeding laceration on the chin but otherwise wel after falling while jumping on his be [patients admitted to the hospital with a ‘alum level af 6.0 me/al. Which of the following symptoms would you NOT expect to se inthis pationt? Numbness in hands and fet. Muscle cramping. Hypoactwe bowel sounds. Positive Chvostek’s san. [Anrse cares fora patient who has a nasogastric tube attached to low suction because ofa suspected bowel obstruction. Which ofthe following arterial blood gas results might be expected inthis patient? pH 7.52, PCO2 54 mm Hg pH 7.42, C02 40.mm Hg 7.25, C02 25 mm He pH 7.38, PCO2 36 mm He [A patients admitted tothe hospital for routine elective surgery. Included inthe ist of current medications is Coumadin (warfarin) at ‘high dose. Concerned about the possible effects ofthe drug, paticularlyina patient scheduled for surgery, the nurse anticipates which of the following ations? Draw 2 blood sample for prothrombin (PT) and international normalized ratio (INR) level ‘Administer vitamin k Draw a blood sample for type and crossmatch and request blood from the blood bank. Cancel the surgery after the patient reports stopping the Coumadin one week previously. a715, The follow lab results are received fora patient. Which ofthe following results are abnormal? Note: More than one answer may be correct. 1) Hemoglobin 10.4 g/6. 2) Total cholesterol 340 me/et. 3) Tota serum protein 7.0 g/l 4) Glycosylated hemoglobin ALC 5.4%. 16, A nurse is performing outine assessment of an IVsite in a patient receiving both 1V ids and ‘medications through the line. Which ofthe following would indicate the need for discontinuation ofthe IV line as the next pursing action? 41) The patient complains of pain on movement. 2} ‘The area proximal tothe insertion site is reddened, warm, and painful. 3) The v solution i infusing too slowly, ‘particularly when the limbs elevated ‘hematoma fvsible inthe area ofthe IV Insertion st. 17, Ahospitalized patient has received ‘transfusions of? units of blood over the past few hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and ‘uncomfortable. On assessment, crackles are heard inthe bases of both Ling, probably Indiating tha the patients experiencing 2 complication of transfusion. Which of the following complications is most likely the cause ofthe patient's symptoms? 1) Febrile non-hemolyte reaction. 2) Allergic transfusion reaction. 3) Acute hemolytic reaction 4) Fluid overioad 18, Apatientin labor and delivery has just received an amniotomy. Which of the following i correct? Note: More than one answer may be correct. 1) Frequent checks for ceria! dation wl be ‘needed after the procedure, 2} Contractions may rapidly become stronger and closer together after the procedure. 3) The FHR etal heart rate) willbe followed closely ater the procedure due tothe possiblity of cord compression. 4) The procedure ie uzualy painless and ic followed by 3 gush of amniotic fi. 2s. a 2 3a) 4) 20 u 2 a 4 y 2) 3) ‘A nurse is counseling the mother ofa newborn infant with hyperbilrubinemia. Which ofthe following instructions by the nurse is NOT Continue to breastfeed frequenty, a least every 2-4 hous. Follow up withthe infant's physician within 72 hours of dizcharge fora recheck ofthe serum bilirubin and exam. \Wateh for sign of dehydration, including decrease urinary output and changes in skin turgor. Keep the baby quet and wade, and place the basing ina cin it area [Anrse'is giving discharge instructions tothe parents ofa healthy newborn. Which of the following instructions should the nurse provide regarding car safety andthe trp home from the hospital? The infant shouldbe restrained in an infant car seat, properly secure in the backseat in a rear facing postion ‘The infant should be retrained in an infant car seat, propery secured inthe font passenger The infant should be restrained in an inrant car seat facing forward or rearward inthe back For the trp home from the hospital the parent may sit inthe back sat ad hold the newboen ‘The nurses consulting a licensed practic nurse about care provided tothe patients on ‘the surgical unit. iis most important forthe ‘nurse to follow up on which ofthe following statements? “The cient who i 3 hours postop after a tonsillectomy i alert and oriented, and swallowing frequently. “The client who is 6 hours postop after a total hip replacement is complaining of increased pain "The cllent wh i218 hours postop ater TURP ‘with continuous bladder irrigation is ‘complaining that he as the urge to voi.” "The client who is 48 hours postop after an ‘Neostomy has loose, dark green, liquid drainage coming from the stoma.” 382. 9 a 3) 4) 23. » 2 3 4 2 ay 21 a 4 2 y 2 3) 4) ‘The nurse prepares a patient fr discharge after cataract surgery. The patients to use ‘external contact lenses, Which of the following information in the patient history ‘most important? ‘The dient takes medleation for hypertension. ‘The dient les In 8 second flor apartment ‘The dient has rheumatoid artis ‘Te cent had previous eye surgery “The nutse reviews the records of clients inthe ‘medical cline wha are at risk to develop type 2 diabetes. Arrange the following clients in ‘order from greatest risk to least isk for {developing type 2 diabetes. 'A26-years-old African American who follows a weight reduction dit and exercses3 times per week. {A b-yeareold Caucasian who delivered an 15 infant, and whose mother-inlaw has type 1 diabetes ‘Aa6.yearsold Asian American who has 2 history of hypertension, and whose blood cholesterol in within normal limits {A:56:yearsold Native American who is 58" tll, ‘weights 200s, and has two slings with type 2 clabetes. ‘A years-old is admitted with persistent ‘vomiting and severe abdominal pain. The eilé is diagnosed with acute appendicitis and scheduled for surgery. The nurse recognizes that which of the following actions i the HIGHEST prosty? {Adminter Demerol 15 mgiM @ 4h. Pinch the skin on the patients inner thigh and releaze. ‘Ask the parents ifthe child has had surgery before Determine ifthe consent for surgery has been signed, ‘A patient comes tothe recovery room following 2 tympanoplasty ofthe right ear. ‘The nurse should take which of the following actions? Position the patont latin bed withthe affected carp, Instill antibiotic drops inthe eat Use paper anda pense to communicate with the patient. Remove the gauze packing inthe canal 26, The nurse on maternity unit must acept a transfor patient from medical/surgical uit. ‘The nurs will consider which ofthe following transfers appropriate? patient witha diagnosis of systemic lupus ‘erythematosus. 2) A patient wth dlagnosis of active tuberculosis 3) A patient with rubella 4) Apatient wth chronic hepatitis. y 2, A 12:years-old boy sustalned 2 crushing injury toh trachea ina car accident. Inthe emergency room a cuffed tracheostomy tube is inserted, Several hours later the nurse enters the patients room and finds the boy in respiratory distress. Which ofthe followings ‘the BEST method for the nurse to use to come to this conclusion? 2) Observe the patient's color. 2) Assess the patient's respiratory ate. 3) Usten tothe patient's breath sound, 4), Check the patiant fr retraction 28, Achildin a new plaster walking cst has swollen toes and diminished pedal pulse. ‘Which of the following actions if taken by the nurse, is MOST appropriate? 1) Get Doppler studies to check the pulse. 2) Notify the physician 3) Determine ifthe casts ry. 4) Obtain the vital signs. 29, A 72-years-old man is admitted tothe hospital ‘complaining of right sided weakness and difficulty speaking. Which ofthe following ‘obzervations, if made by the nurse, is MOST important? 4) Patients 6 fet tall and weighs 150 pounds. 2) Patient requires the use of acane to ambulte. 53) Patient responds to the speaker only when the speakers in font of im 4) Patient hasan open cut onthe left temple Frx 1 2) 3 4 3 y 2) 3) ) ) ) 1. a) 2 y 2) 3) 4 3: 1 2 a 4 ‘The Homecare nurse i planing client visits of the day. Which ofthe following patients should the nurse see FIRST? [A oyears-ald diabetic with fasting blood tlucose reading of 240-260 mg/dl for one week 65.years old discharged from the hospital two days ago following coronary artery bypass surgery (CABG). |AS5.yearsold with congestive heart failure who gained 3 bs inthe lst 24 hours. ‘A40.yearsold with metastatic breast cancer complaining of pain unreioved by pain medication ‘Anurse is performing triage in the emergency ‘department, Which ofthe following patients should the nurse see FIRST? patient with a fracture L femur, BF 110/60, P86, R 20,799. (37.3¢). A patient complaining of a headache, {BP 160/100, P76, R 18,7 98.4 (36.8) ‘Apatient with burns onthe face, chest and hands, BP 120/80, P 100,824,198. F (37.20), ‘patient with Type 1 diabetes in ketoacidosis, ‘BP 100/60, P 100, R26,7 99.4F(37.4C) [AGo-years-old mans admitted to the hospital with adiagnosis of chronic bronchitis. The nurse should Position the patient on his side Lay the patient fit with feet slighty elevated, Elevate the head ofthe bed 60" Elevate the head ofthe bed 30°. The Home care nurse is performing health screening atthe local mall. The nurse knows that which of the following clients s at HIGHEST risk to experience a cerebral vascular accident (CVA)? 1) 32-year-old Caucasian female with a history of Type 1 clabetes melitus and oral contraceptive use for 8 years. ‘4.49-yearsold Caucasian male who works as an ‘account executive at an ad agency and has 3 cholesterol level of 250 mal. |AS6-years-old African American female with history of mitral valve prolapsed and smoking cigarettes for 30 years ‘8 69-yearsold African American male witha history of hypertension and 30 pounds overweight, 34, Adildis admitted tothe hospital with a siagnosis status asthmatius. The nurse would ‘be MOST concerned if which of the following was observed? 4) 520281% 2}, expiratory wheezing 3) intercostal retraction 4) p75, 35, The physician orders furosemide (Lasix) and spironolactone (Aldactone). Prior to ‘admiojstering Lasix and Aldactone, the nurse determines thatthe patients potassium level 153.2 mEq/L. The nurse should. 1) Hold the Lasi and Aldactone. 2), Administer only the Aldactone 3) Administer only Lasix 4) Administer the Las and Aldactone. 236. A registered nurse from a surgical floors ‘reassigned toa medical Unit. Which of the following assignments is MOST appropriate for this nurse? 41) Apatient with Type 1 dlabetes scheduled for discharged at 2 pr, 2). Apatient admitted 4 hours ago with a diagnosis of myocardial infarction. ‘Apatient with Alzheimers that requires a tube feeding 4) patient admitted yesterday with dagnosis of left-sided cerebral vascular accident. a £37. A nurses planning client and unit activity for ‘the day. Select the activities thatthe nurse should delegate to the nursing asistant. Select all that apply. 4) Deliver fresh water to clients. 2}, Empty urine out of Foley bags 3) Take temperature, pulse, respiration, and blood pressure. ‘Count the substance control medications in the narcotie mediation supply (Check the rash cart (CPR cart) for necessary supplies using a checklist. 6} Checkall intravenous (1) solution bags on clients recehing V therapy fr the remaining ‘amounts of solution inthe bogs. 4 5) “038, The nurse 0 wear this protective device (refer to figure below) when eating for cents with whieh ofthe following disorders? 41, The nurse would use this type of restraint (See figure below) in which ofthe following situations? Select all that apply. hata 4) To secure the shoulders and the walt 2} To immobilize a client's am and shoulders. 3) To prevent the cient from getting ou of bed 4) Toprevent dislodgement of an intravenous line 5} To prevent the clent from turning from sdeto side ‘To prevent the use ofthe hands while allowing fove atm movement 41) Scabies 2} Tuberculosis 3) Hepatitis A 4) Pharyngeal diphtheria 5), Respiratory viral influenza 6) Meningococcal pneumonia 4 39, Wrist restraints have been prescribed fora client who fs continuously pling at his {gastrostomy tube. The nurse develops a care plan and determines that which of the following i unexpected outcomes related to the use of restraints? Select al that apply ‘The cent is agitated, ‘The client’ left hand i pale and cole ‘The client's skin under restraint fred ‘The client verbalies the reason for the restraints. ‘The client Is unable to reach the gastrostomy tube with his hands. The client sip his hand out of the restrain and pulls at is gastrostomy tube >. A hospitalized client is found lying onthe floor next to the bed. Once the client is cared for, the nurse completes an incident (regular occurrence) report. Select the writen statements tha identify incorrect ‘documentation on the report. 1) The client fell out of bed 2). No bruises or injries are noted on the cent. 3) The client apparently climbed over the side ais when the nurse was out ofthe room. 4) The physician was notified that the client was found yng on the floor next tothe bed. 5) The cliontis alert and oriented and stated that he needed to “goto the bathroom and didn't want to bother the nurse.” 42, homecare nurse is visting an older client ‘who has been recovering from a mild brain attack etroke) affecting the left side. The ‘ent lives alone but rectves regular assistance from her daughter and son, who both ive within 10 miles. To assess for risk factors related to safety, the nurse should do ‘which of the following? ‘Selec all that apply. 2) Assess the cient’ visual acuity. 2) Observe the client's gat and posture. 3) Evaluate the clen's muscle strength. 4) Lookfor any hazards inthe home care 5) Aska family member to move in with the client until covery is complete Request that the client transfer to assisted ving acy, 4 43, Which fluid would be the most appropriate for 1a client receiving furosemide (Lasix) and igoxin (Lanoxin) 3) mi 2} Gatorate 3) Orange juice 4) water‘44, List in order of privity how the nurse should best schedule morning activities for assigned clients, (isthe fist activity and #6 isthe last activity) 1) Make rounds and assess assigned clients 2), Recelverepor from the previous nursing shift 43), Administer medications scheduled before breakfast. 4}, erform dally dressing changes and other 5) Document nursing care and other pertinent information in the client's record 6}. Ensure that clients receive breakfast and receive hygiene care by nursing asistant. 45, The nurse enters a client's room to administer ‘the Bam medications and notices thatthe lien isin an awkward position in bed and has rot eaten breakfast, What i the nurse! ‘briority action? 1) Ask the client to state his name 2}, Feed the client his breakfast 43}, Correct the client's position in bed 43}, Administer the client's medications 46, 36-years-ola woman has undergone a lett radical mastectomy for invasive cancer. The nurse correctly interprets thatthe cients having dtficlty adjusting tothe loss of her breast if which ofthe following behaviors s observed? 1) Te client refuses to look at the dressing or surgical incision, ‘The cent is asking for pain medication every 3 ours 3) The client asking questions about the information on her postoperative care pamphlet ‘The client is performing arm exercises only one ashi 2 4 447, Afemale dient is admitted to the emergency room after being attacked bya stranger. She told police she was robbed and raped at kolfepoint. The client appears elm and Is sitting qulety inthe exam room. The nurse correctly identifies her behavior asthe protective defense mechanism known as: 48, a 2) 3) 4 st » 2) 3) 4 52. 0 2) 3) 4) [healthcare practitioner who provides clients with incorrect or netigent treatment might be ound gulty in a court of aw of Adlent isin need of increased protein intake, When selecting food items from the menu for the next day's meal, the nurse assist the dent in appropriately choosing al ofthe following items except Yogurt Lomfat cheese Bacon Cooked beans Aclient s admitted to your unit and is ordered tobe on intake and output. The client consumed the fellowing fluids! 1 ep of coffee Ts ounces of orange juice Ts ounces of water aap of eto reap oftea Tsounces of broth Tsounces of water client record {A7e-years-old woman s admitted to your unit with fracture ofthe femur. When assessing the client the nurse suspects fat embolism. Which ofthe folowing assessments will the nurse consider the earliest symptom of low ‘arterial blood flow? Respiratory stress. Confusion, yan. A temperature of 101.8" F ‘The nurse's neighbor comes over to say that he jst burned her arm onthe stove. The ‘nurse should advise the nelghbor todo which ofthe following fst? ‘ppl ice to the burn ‘Apply antibacterial ointment tothe burn Pour cool water over the bun. Wrap the burn ina clean cloth 253. En 2) 3) a sa a 2 3) a ss. PN 2) 3) 4 A postoperative cients recovering neely. ‘Which of the following foods would the nurse ‘encourage the cient to select from the food ‘menu to aid in the healing ofthe surgical wound? ‘Abacon, egg, and cheese sandwich, Chicken and orange slices, Green tea and cheeseburger ‘Apork chop and buttered noodles. [A physician orders medications fora newly admitted to your unit. On review ofthe physician's orders, you notice the dose is three times normal. You cll the physician's office and are told he will not be avalable for seve days. What s our next priority nursing Intervention? Contact the pharmacy and confirm the dosage Issafe to administer, \Withhold the medication until the ordering physician canbe reached, Contact the answering service and speak with the covering on-call physician Document your concerns and administer the medication as ordered, [postoperative client returns tothe unit from post anesthesia care unit (PACU). Which ofthe following i the nurses priority assessment? ‘The intravenous fluid and intravenous site The level ofthe cients pain “The surgeal dressing, The patency ofthe client's nasogastric tube ‘Anursois caring fora postoperative client. The nurse knows thatthe most reliable Indication ofthe existence and intensity ofthe client's acute pain is which of the fllowing? ‘Assessment of the client's via signs, The cient self reporting of pain A visual assessment ofthe client. The severity ofthe surgical procedure causing the pain 57. The nurse notes that her dient recelving 2 transfusion is having a reaction. The prieity ‘nursing intervention includes all ut which of the following? 2) Discontinue the current intravenous site and start an infusion a a diferent ste. 2), Start an intravenous infusion of normal saline to run at 30 ml per hour 3) Assess the client's ital signs ever 5 minutes 4) Prepare the blood bag and blood slp to be return t the blood bank 58. A dient working at a chemical plant was caught in an explosion. He was rescued by his Coworker and presents in the emergency department with thid- degree chemical bros ‘over more than 25% of hls body. What i the priority nursing intervention for this clint? 4) Fluid resuscitation 2} Medica for pain, 3) Administer tetanus toxoid 4) Establish and maintain a patent airway. 59, A dient is diagnosed with fbrocystic breast disease. When teaching the client about iotary changes to help inthe treatment ofthe tisease, the nurse should instruct the cient 10 ‘do which of the following? 2) nrease sodium inher diet. 2) rink only bottled water. 3) Limit her intake of ealeiom 4), Decrease her intake of caffeine 60, AS8-years-old woman is brought to the emergency room after being involved in 8 ‘motor vehicle accident. Shortly after ‘admission, the client's husband arrives. He is distraught and is blaming himself for the accident because he did not drive her himselt What is the nurse’s most appropelate initial respond? 2) Reassure the husband that his wife wil be ne 2) Allow the husband to see his wife immediatly. 3) Detail the wife's injuries and plan for treatment. 4) Allow the husband to verbalize his feelings and fears a6 3 2 3) 4) 4) 2) a 4a) 5) 6, 0 2) 3) 4 5) 4 64, uv 2) 3) a 3) 8 I. Aclent i schedule fora bone marrow Aspiration. He asks the nurse about possible sites that could be used forthe procedure. The rurse tells the client that in addition tothe lia eres; the most common site for bone ‘marrow aspiration is which of the following? ‘The femur. ‘The humerus. ‘The sternum, The it, ‘Anursing home nurse enters the day room and finds the window curtains on fore. Clients are panicking andthe room siling with smoke. The nurse acts quickly ad performs all af the following actions. Number the nuesing actions inthe priority order the nurse would complete them. Close the door. = sound the alarm Remove the residents from the room. Document the nurse's observation Teingush the fire. ‘The nurse is preparing the client assignment {for the day and needs to assign clients toa Neanted practical rsa (UPN) and 3 nrsing ‘astatant, Which clients should the nurse ‘assign to the PN because of clients needs that cannot be met bythe nursing assistant? ‘Select all that apply, ‘lint requiring frequent suctioning ‘Alene requiring a dressing change tothe foot ‘client requiring range-of-motion exercise twice 3 da, A client requiring reinforcement of teaching about a diabetic diet Alint on bed rest requiring vital signs measurement every 4 hours. ‘alent requiring collection ofa urine specimen {for urinalysis testing, Percussion i a physical assessment technique that s ured to assess which ofthe folowing? Select all that apply Fluid in body cavities. Borders of body organs. Consistency of body organs. Mobility of organs and other structures. Resilience and resistance of tissue nd organs. Location, site, and density of an underying structure, 6. a 2) 3) 4 3) 6 6 9 a 3) a 5) 6 67 » 2) 3) 4 5) o [Alien arsives at the heath care cline complaining of a cough. Uistin order of priority the steps thatthe nurse takes to assess the lent, (Number 1s the fist step and ‘number 6's the iaststen} Introduee sefto the client. Auscultate the thorax for breath sound, Inspect the anterior and posterior thorax. Percuss the anterior and posterior thorax. Palpate the anterior and posterior thorax. (Obtain data regarding complaints and personal and fait history. ‘The nurse provides information toa client about performing abreast self examination {8SE). The nurse determines thatthe client ‘needs adlitional information if the client ‘makes which statements? Select al that apply. "The BSE needs to be done monthly.” "Lumps in my armpit area ae normal." “tcan palpate my breast with soapy water while showering.” “should perform the examination onthe day that start my period” "When squeeze my nipples |! should expect tomnote some discharge.” “I should stand before 3 miror and inspect each breast for anything unusual” ‘The nurse is performing a socioeconomic assessment of a Chinese clint. Which ‘questions would be appropriate forthe nurse to-ask? Select all that apply. What do you do for ving?” “How much money do you make year?" “Do you havea primary heath care provider?” “How many years of school did you complete?” “How diferent is your if here from in your homeland?” "what type of work did you do back in your homeland?” “