Nutrition
Name all three macronutrients and the two subcategories of micronutrients.
Carbohydrates, Lipids, Proteins are macronutrients. Vitamins and minerals are micronutrients.
A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client?
A. Avoid beverages that contain caffeine
B. Take a sleep medication regularly at bedtime
C. Watch television for 30 min in bed to relax prior to falling asleep
D. Advise the client to take several naps during the day
Correct answer A
Caffeine is a stimulant, so the nurse should advise them not to drink.
Why NOT B? Sleep medication should be last resort. The nurse should not recommend this unless they have recommended and tried non-pharmacological interventions first.
What is extravasation and what are the signs and symptoms?
IV infusion that enters tissue and not the vein but THE SUBSTANCE IS TOXIC
IV site swelling, burning, blistering is late sign, blanching or coolness is early sign.
A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take?
A. Document the administration of the medication
B. Count the amount of available medication on hand and sign for it
C. Measure the client's respiratory rate
D. Check the medication dose and the client's identification
Correct Answer: D.
Check the medication dose and the client's identification The "rights" of medication administration include verifying the right client and the right dose.
A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?
A. 3+ Achilles reflex
B. Faint pedal pulses
C. Feet warm to the touch bilaterally
D. Capillary refill of <2 sec
Correct Answer: B. Faint pedal pulses Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity.
A nurse is evaluating a client's need to lose weight. Her body mass index is 28.3. Which of the following BMI applies to her?
A) Overweight
B) Obese Class I
c) Obese Class II
A overweight. 25 to 29.9 is overweight. 30 to 34.9 is obesity Class I. >35 is Class II.
A nurse in a provider’s office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client’s sleeping difficulties?
A. "I take a warm shower when getting ready for bed."
B. "I often have a cup of coffee with my dessert before going to bed."
C. "I usually read a chapter in a book before I go to bed."
D. "I make sure I do my exercises in the morning."
B is correct
What is the difference between obstructive sleep apnea and central sleep apnea? What are some risk factors for both?
OSA = soft tissue of pharynx and soft palate collapse and tongue falls into back of throat obstructing upper airway. Defined by at least 5 witnessed breathing interruptions/awakening from gasping. Risk factors = being male, over age 40, black or latino, overweight, alcohol, smoking, sleep meds, large neck size
CSA = Brain isn't sending the proper signal, nothing is PHYSICALLY blocking airway. Risk Factors = prematurity, meds, head trauma, brainstem issues
A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible?
A. Stat prescription
B. PRN prescription
C. Standing prescription
D. Single prescription
Correct Answer: A. Stat prescription
A stat medication prescription is carried out immediately or as soon as possible and for one time only.
Incorrect Answers: B. A PRN medication prescription medication is given as needed. C. A standing medication prescription indicates the frequency a prescribed medication is administered on a daily basis and might not have any specific date of cancelation. D. A single medication prescription refers to administering a medication once at a specified time.
A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?
A. Hydrocolloid
B. Collagen
C. Calcium alginate
D. Proteolytic enzyme Correct
Correct Answer: A. Hydrocolloid The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin. Incorrect Answers: B. The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing. C. The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of dressing is used for wounds with significant exudate and must be covered with a secondary dressing. D. The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. This type of dressing is applied to facilitate debridement and to soften eschar. Peer Comparison A 82% B 7% C 7% D 4% Difficulty level: Easy
Which action can a nurse delegate to assistive personnel (AP)?
1. Performing glucose monitoring every 6 hours on a patient
2. Teaching the client about the need for enteral feeding
3. Administering enteral feeding bolus after tube placement has been verified
4. Evaluating the client's tolerance of the enteral feeding
1. Performing glucose monitoring every 6 hours
A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?
A. The client watches television in her bed during the day.
B. The client drinks warm milk before bedtime.
C. The client goes to bed at 2200 every night.
D. The client gets up to use the bathroom once during the night.
✔Correct answer A : To promote sleep the client should only use the bed for sleep or sexual activities, not for watching TV
Why NOT B: If going to sleep at 2200 is part of the sleeping routine of the client, it is encouraged to keep and establish a regular sleep schedule
A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?
A. Obtain the prescribed irrigation solution
B. Don personal protective equipment
C. Check the client’s pain level
D. Place a waterproof pad under the client’s extremity Perfect!
Correct Answer: C. Check the client’s pain level The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions.
A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make?
A. "Call me when you are ready, and I will return with the medication."
B. "Since you were taking this medication at home, I will leave it for you to take."
C. "I will come back in 30 minutes to check that you took the medication so I can chart the time."
D. "If you refuse to take the medication now, I can’t give it again until your next scheduled time."
Correct Answer: A. "Call me when you are ready, and I will return with the medication." The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration.
A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "I will use a staple remover and remove each suture individually."
B. "Bandage scissors are used to cut the sutures."
C. "Tweezers are necessary only for removing retention sutures."
D. "I will clip each suture close to the skin and pull it through from the other side." Correct
Correct Answer: D. "I will clip each suture close to the skin and pull it through from the other side." Clipping close to the skin and pulling the suture from the other side does not disrupt the wound-healing process.
What type of diet would a person be perscribed post jaw surgery when they have very limited mobility to open and close their mouth?
Full Liquid Diet
Explain the difference between a Dyssomnia and a Parasomnia.
Dyssomnia is characterized by insomnia or excessive sleepiness Ex: Insomnia, circadian disorders, sleep apnea, restless leg, narcolepsy
Parasomnia is patterns of waking behavior that appear during sleep Ex: sleepwalking, sleeptalking
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply.)
A. Gingivitis
B. Dry, brittle hair
C. Edema
D. Spoon-shaped nails
E. Poor wound healing
Correct Answers: B. Dry, brittle hair C. Edema E. Poor wound healing
Dry, brittle hair that falls out easily suggests inadequate protein intake and malnutrition. Edema can occur when albumin levels are lower than the expected reference range and indicates protein-calorie malnutrition. Adequate wound healing depends on the ingestion of sufficient protein, calories, water, vitamins (especially C and A), iron, and zinc.)
Incorrect Answers: A. Gingivitis is a manifestation of vitamin C deficiency. D. Spoon-shaped nails are a manifestation of iron deficiency.
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client’s bedside and perform which of the following verification procedures?
A. Check the client’s name and medical record number on the MAR against the room and bed number
B. Call the client by name and check the name on her identification band against the MAR
C. Compare the medical record number and name on the MAR with the client’s identification band
D. Ask the client’s visitor to identify the client by name and to state the client’s birth date
Correct Answer: C. Compare the medical record number and name on the MAR with the client’s identification band
The Joint Commission requires the use of 2 client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client’s identification band.
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform?
A. Wear sterile gloves when collecting the specimen
B. Cleanse the wound with 0.9% sodium chloride irrigation
C. Allow the collection swab to absorb old exudate
D. Rotate the collection swab over the edges of the wound Correct
Correct Answer: B. Cleanse the wound with 0.9% sodium chloride irrigation The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate.
Incorrect Answers: A. The nurse should wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab. C. Pooled drainage can collect microorganisms that are not the pathogens causing the wound infection. D. The nurse should rotate the swab back and forth over clean areas in the base of the wound to collect the pathogens causing the wound infection. The edges of the wound can harbor superficial microorganisms from the skin that are not infecting the wound.
An RN receives the change-of-shift report about these clients. Which client does the nurse assess first?
A. 30-year-old admitted 2 hours ago with malnutrition that is associated with malabsorption syndrome
B. 45-year-old who had gastric bypass surgery and is reporting severe incisional pain
C. 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL
D. 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min
D. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. This client needs respiratory assessment and interventions immediately.
Think of the ABCDEs and how airway and breathing are the first priorities
A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?
A. Gradual memory loss
B. Reduced level of consciousness
C. Difficulty with abstract thought
D. Verbalized feelings of hopelessness
✔Correct answer B
The nurse should expect a reduced level of consciousness, sudden memory impairment, illogical thinking, and sleep disturbances.
A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
A. Abdominal binder
B. Montgomery straps
C. Hypoallergenic tape
D. Plastic tape Perfect!
Correct Answer: B. Montgomery straps The nurse should apply the least-restrictive priority-setting framework, which assigns priority to nursing interventions that are the least restrictive to the client, as long as those interventions do not jeopardize client safety. Least-restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff members, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation of the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties are secured again without removing the adhesive strips.
Incorrect Answers: A. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed; however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less-restrictive intervention first. C. Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse should use a less-restrictive intervention first. D. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less-restrictive intervention first. Peer Comparison A 12% B 55% C 32% D 1% Difficulty level: Hard
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?
A. Instruct the client to blink several times after instilling the medication
B. Ask the client to look straight ahead during instillation of the medication
C. Apply pressure to the puncta after instilling the medication
D. Place each drop of the medication directly onto the client’s cornea Correct
Correct Answer: C. Apply pressure to the puncta after instilling the medication The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?
A. Use a 10 mL syringe
B. Attach a 22-gauge catheter to the syringe
C. Warm the irrigating solution to 37°C (98.6°F)
D. Administer an analgesic 10 min before the irrigation
Correct Answer: C. Warm the irrigating solution to 37°C (98.6°F) The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction.
Incorrect Answers: A. The nurse should use a syringe that has at least a 30 mL capacity. B. The nurse should use an 18- or 19-gauge catheter. A smaller catheter will exert too much pressure on the wound. D. The nurse should administer an analgesic 20 to 30 minutes before the irrigation to give the medication enough time to provide pain management during the procedure.