Assessments
A nurse is performing an assessment to check a client's balance. What is this test called?
Romberg's
When a nurse is preforming ostomy care, oral care, colleting a lab specimen, or emptying a foley bag, they should wear what type of PPE as a priority?
Gloves
When a client has an infection, what is the main lab that result that would be elevated ?
WBC
The nurse refuses to let the client leave the hospital, what ethical violation has occurred?
False Imprisonment
A nurse finds a patient on the floor after a fall. What is the first action?
Assess the client
The nurse is assessing urine characteristics for a client who has an indwelling Foley catheter How would the nurse obtain an accurate assessment?
Assess the urine in the tubing
The client lying down has an oxygen of 82 percent, what should the nurse do first?
Sit the client up
What lab would be low for a malnourished client?
Albumin
What action would the nurse take prior to medication admiration for an unfamiliar medication?
Look up the medication information in the medication reference book
The nurse is assigned to four pediatric patients. Which child should be seen first?
A. A child with a fever of 101°F and sore throat
B. A child with a fractured arm in a cast complaining of itching
C. A child with asthma who is using accessory muscles to breathe
D. A child with mild diarrhea who is drinking fluids
Correct Answer: C
Rationale: Respiratory distress is an airway issue and takes priority over other conditions.
What are the normal vital signs for an adult?
Adult Values
Temp 96.8 ° F- 100.4 ° F
RR 12-20/min
Pulse 60-100/min at rest
BP <120/<80
pOx 95%-100%
What vital signs need immediate follow up?
Temperature 39.6º C (103.3º F)
Blood Pressure 190/104 mm Hg
Heart Rate 130/min
Respiration rate 12/min
Oxygenation saturation 93% on room air
RR, B/P, and HR
A client present with these lab results, what is likely happening?
Sodium 155 mEq/L
Potassium 3.8 mEq/L
BUN 26 mg/dL
Dehydration
Oral fluids
A nurse in a community health clinic is administering immunizations. The nurse provides education on the vaccine and allows the client to The protection from illness but all the client to choose. Which ethical principle is the nurse explaining in this situation?
Autonomy
A nurse is preparing to transfer a client from a wheelchair to the bed. What would the nurse need to determine first prior to the transfer?
Can the client bear weight
What are some clear liquid diet choices?
Broth, apple juice, tea, clear soda,
Reliable indicator of fluid loss?
Weight
How would the nurse administer a prescribed buccal medication?
Place the medication between the gum and cheek.
Instruct the patient not to chew or swallow the medication.
Allow it to dissolve completely for proper absorption.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
2. A client with chronic kidney disease who has a serum potassium level of 6.2 mEq/L.
A client in fluid overload would have _______ pulses.
Bounding
A nurse is assessing a client's radial pulse and finds that the pulse is irregular and thready.
Listen to the apical pulse for a full minute
feeding technique for a client with poor gag reflex and Dysphasia ?
Flex head with chin tuck
What is an idiosyncratic event?
Unpredictable and not related to the drug’s known pharmacological action.
How can a public health nurse communicate information to a large crowd and rapidly?
Post information on the health department's website