Wounds & Drains & Injections
When emptying a JP drain, the nurse measures 30 ml of clear drainage AND drainage with pus. This drainage would be documented as
Seropurulent
A student nurse encounters an unresponsive client in a waiting room. The client is not breathing and has no carotid pulse or respirations. What is the first step the student nurse should take?
Begin cardiopulmonary resuscitation (CPR).
The nurse is interviewing a client that has been diagnosed as an alcoholic who states “I can quit drinking any time I want to.” The nurse knows this defense mechanism is an unconscious refusal to see reality known as
Denial
The nurse provides care to a patient who is dying of colon cancer who states, “I know I can beat this cancer if I just change the things that I eat.” Based on Kübler-Ross’ stages of grief, which stage does the nurse document in the medical record that the patient is experiencing?
Bargaining
A client recovering from an amputation asks why the foot that was removed is still causing pain. Which type of pain should the nurse explain that the client is experiencing?
Neuropathic
During a routine admission skin assessment, the nurse finds a wound over the client's coccxy that shows full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue, but not involving muscle or bone. The nurse would document this as a
stage III pressure ulcer
The nurse calls the physician and provides the following statement during ISBARR communication: "Mr. Alan Jones was given Mr. Alex Jones’s medication in error at 9 a.m." Which part of ISBARR information did the nurse provide with this statement?
Situation
The nurse has a co-worker that as a teenager he hated the sight of blood but then went on to become a phlebotomist. The nurse knows that this person that developed the exact opposite trait of a perceived inadequacy is exhibiting the defense mechanism known as
Reaction formation (overcompensation)
The nurse provides care to a patient who is prescribed palliative care. The patient asks, “What is the difference between hospice care and palliative care?” Which does the nurse include in the response to the patient regarding palliative care?
It may be aggressive and is directed at eliminating discomfort.
A client asks why the shoulder is hurting when the problem is in the abdomen. Which type of pain should the nurse explain this client is experiencing?
Referred
The nurse is preparing to provide an intramuscular injection to a newborn client. Which size needle is appropriate for this client?
3/8-inch
A 22-year-old male has a sore throat and runny nose, so he calls his mother to seek advice for treating this illness at home. Which phase of illness is this person experiencing?
prodromal phase
The nurse is interviewing a client that is crying. The client states “I wasn’t really sad; I'm just a little tired.” The nurse knows that expressing an emotion that is separated from the original feeling is a utilizing a defense mechanism known as
Isolation
The nurse provides care to a patient who is actively dying. The patient’s spouse is upset about her husband’s respirations. Which response by the nurse is appropriate when providing education to the spouse about Cheyne-Stokes respirations?
“As your husband approaches end of life, breathing will be a cycle of shallow and deep respirations.”
A client experiencing pain rated as a 7 on a scale from 1 to 10 continues to have pain despite having medication 2 hours ago. Which response should the nurse make when the client requests additional medication?
“Let me reposition you and rub your back to help relieve the pain”
The nurse recognizes that a 22 g ´ 1.5-inch needle would be most appropriate for a(n):
Adult intramuscular (IM) injection
A client being seen in an urgent care clinic reports having pain on the right side of the abdomen. In which phase of illness is this client?
Seeking help
An LPN/LVN is assisting the RN in caring for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client cares for a spouse at home who also has COPD. When formulating a nursing diagnosis for this client, the RN selects “Readiness for enhanced knowledge.” The RN then sits down with the client and presents the information included in his or her teaching plan. Which step in the nursing process would this be considered?
Implementation
A terminally ill patient refuses to take adequate pain medication. The patient expresses worry that the use of pain medication may result in addiction. Which response by the nurse is appropriate?
Teach the patient that addiction is not a concern during the terminal stages of illness.
A nurse's client is suffering pain 7/10 as a result of a fracture to his right ulna. The nurse understands that this type of pain is
Deep somatic pain
In newborns, infants, and toddlers, what is the muscle of choice for IM injections?
the vastus lateralis muscle
An older client with a chronic illness lives alone, has a fixed income, and often cannot afford required medications. How would the nurse describe this client's health status?
Poor health in an unfavorable environment.
As a patient ages, he or she is more likely to suffer from changes to neurological function; which of the following could be a neurological side effect of aging?
transient ischemic attack (TIA)
When conducting an admission assessment, the nurse correctly recognizes which information as objective data?
a. a client's statement of feeling depressed
b. a client's description of anxiety
c. a client's family history
d.a client's fruity-smelling breath?
d. A client’s fruity-smelling breath
What is the function of Neutrophils?
Responds to bacterial infections.