Communication and Documentation
Communication through facial expressions and posture is called what?
Nonverbal communication.
What does the pulse oximetry measure?
arterial blood oxygen saturation
You are caring for an older client with decreased mobility and visual impairment. What are they at risk for?
Falls
Name one sign of dehydration.
Acceptable answers: Dry mucous membranes, tachycardia, low urine output.
Correct order of abdominal assessment?
A: Inspect → Auscultate → Palpate
What type of statements must be avoided in charting?
Judgmental or subjective statements.
Heart rate of 51 is called what?
bradycardia
Name three nursing interventions that help prevent falls in the home.
Possible answers:
1. remove rugs/ clutter
2. turn on lights
3. proper use of ambulatory aids
A client has a stroke and is having difficulty swallowing. What kind of modified consistency diet would the nurse anticipate?
Pureed diet, thickened liquids
Minimum normal adult urine output per hour?
30 mL/hr.
First step when a patient refuses treatment or medication?
Assess and explore the reason; document.
Crackles in the lungs indicate what?
Fluid in alveoli (CHF, pneumonia).
Administering vaccinations at a local health clinic is considered what level of health promotion/ illness prevention?
Primary
When the nurse reviews the client’s laboratory reports revealing sodium, 152 mEq/L; potassium, 4.1 mEq/L; calcium, 8.7 mg/dL, and magnesium, 2.1 mg/dL; the nurse should notify the physician of the client’s:
hypernatremia
A client with an ileostomy will have what consistency of stool?
Liquid
What must nurses consider about themselves when assessing clients from other cultures?
Their own cultural orientation.
Best pain scale for nonverbal patients?
A: FLACC or behavioral scale.
A client with measles is admitted to the unit. What transmission-based precautions will be used?
Airborne
A patient's arterial blood gas measurements read pH = 7.31, PaCO₂ = 49 mmHg, HCO₃ = 30 mEq/L. How would you interpret this?
Respiratory Acidosis
A client experiences constipation. Name 3 nonpharmacologic nursing interventions to promote a bowel movement.
1. Movement
2. Foods high in fiber
3. Increase fluid intake
Purpose of a narrative nursing note?
Chronological, detailed record of assessments and interventions.
A patient presents with shortness of breath, use of accessory muscles, an SpO₂ of 89% on room air, and crackles in the lower lobes. The nurse’s assessment reveals tachycardia and restlessness.
Based on these findings, what is the nurse’s PRIORITY action?
Raise the head of the bed and apply supplemental oxygen, then reassess the patient’s respiratory status.
List the 4 stages of infection in order.
Incubation period
Prodromal stage
Full (acute) stage of illness
Convalescent period
A client has hypernatremia, what type of fluid do we anticipate the client getting?
0.45% Normal Saline (½ NS)
(Hypotonic solution)
Diarrhea increases loss of which electrolyte?
Potassium (K⁺)