This is Vital
A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. From this information, the nurse should identify that the client is receiving which of the following oxygen concentrations?
28%
The nurse is assessing a patient who may be in the early stages of dehydration. Early signs and symptoms of dehydration include:
Thirst and confusion
Which patient is at the greatest risk for impaired wound healing after surgery?
a. A 75-year-old patient with poorly controlled diabetes mellitus
b. An 85-year-old patient in generally good health
c. A 60-year-old patient who is slightly overweight
d. A 65-year-old patient with hypertension
A 75-year-old patient with poorly controlled diabetes mellitus
The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective?
Sign
An 82-year-old male with Parkinson's disease experiences frequent urinary incontinence. The nurse should perform which intervention first?
Request an order from a condom catheter
The nurse is caring for a patient who was given pain medication before leaving the operating room. Upon returning to her room, the patient states that she is experiencing pain and requests more pain medication. Which is the best action for the nurse to take?
Notify the practitioner that the patient is continuing to experience pain
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include?
Check the client's weight each morning
Change gloves between tasks on the same client
Which areas should be included in a neurovascular assessment?
Capillary refill time, movement, pulses, and warmth
What are the three landmarks for NG tube insertion?
Tip of nose
Lobe
Xiphoid
When locating the apical pulse, the nurse should place the stethoscope at the:
Fifth intercostal space near the midclavicular line
An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?
Dehydration
Thick yellow drainage is called
purulent
A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next?
Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply.
a. Closely assess the patient before, during, and after the procedure
b. Hyperoxygenate the patient before and after suctioning
c. Limit the application of suction to 20 to 30 seconds
d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve
e. Use an appropriate suction pressure (80-150 mmHg)
f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
a, b, d, e
a. Closely assess the patient before, during, and after the procedure
b. Hyperoxygenate the patient before and after suctioning
d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve
e. Use an appropriate suction pressure (80-150 mmHg)
A patient with cancer develops pulmonary edema. During chest auscultation, which breath sounds should the nurse expect to hear?
Crackles
A nurse is reinforcing teaching about fluid replacement to a group of junior high athletes. Which of the following liquids should the nurse include as a priority to provide adequate hydration?
water
After the initial phase of a burn injury, the primary focus of a patient's cure is:
Preventing infection
The nurse assessing a patient's capillary refill in the hands finds that it took 5 seconds for the color to return. The most appropriate intervention to do following this assessment is to:
Assess the radial pulse and the blood pressure bilaterally
The patient has an indwelling urinary catheter, and urine is leaking from a hole in the collection bag. Which nursing intervention would be most appropriate?
Remove existing catheter and collection bag and replace it with a new one
A patient, age 63, is admitted with acute bronchopneumonia. The nurse notes that he is in moderate respiratory distress. The patient has a history of emphysema-type chronic obstructive pulmonary disease (COPD). The practitioner orders strict bed rest. Which position would help the patient feel most comfortable?
High Fowler's position, using the bedside table as an arm rest
A patient drank a 18 ounces of juice how many ml is that?
540 ml
The nurse is evaluating a postoperative patient for infection. Which sign or symptom would be most indicative of infection?
Redness, warmth, and tenderness at the incision site
A nurse records absence of bowel sounds after assessing the abdomen in:
All quadrants for 3 minutes each
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? Select all that apply.
a. Auscultate bowel sounds
b. Assist the client to an upright position
c. Test the pH of gastric aspirate
d. Warm the formula to body temperature
e. Discard any residual gastric contents
a, b, c