Communication
When interviewing a client. which nonverbal behavior should a nurse employ?
Sitting squarely. facing the client.
When interviewing a client. the nurse should employ the nonverbal behavior of sitting squarely. facing the client. Facilitative skills for active listening can be identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S). open posture when interacting with a client (O). leaning forward toward the client (L). establishing eye contact (E). and relaxing (R).
What does responsibility mean related to delegation?
The task is within the delegator's scope of practice or something for which they could be responsible
Applying the same infection control procedures on all clients is a practice known as
Standard Precautions
Sodium (Na)
What is 135-145 mEq/L
A home care nurse is working with a diabetic patient with poor tissue perfusion. Based on the nurse’s knowledge of this condition, which of the following effects would the nurse most likely see in the patient’s extremities?
a. Sweaty skin
b. Increased venous return
c. Poor hair and nail growth
d. 3+ peripheral pulses
What is c? "Poor hair and nail growth" is correct. A patient with poor tissue perfusion will likely demonstrate abnormal patterns of hair and nail growth on the hands and feet. This occurs because of peripheral arterial disease (PAD). PAD is a chronic disorder in which the lower extremities are deprived of nutrients and oxygen due to impaired arterial blood flow, resulting in tissue damage, pain, hair loss, dry skin, thickened toenails and cold skin in the lower extremities.
The nurse caring for a client diagnosed with a stroke is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item would the nurse eliminate from this client's diet?
1. Spinach
2. Custard
3. Scrambled eggs
4. Mashed potatoes
1. Spinach
A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations?
"You appear to be talking to someone I do not see.”
The nurse is making an observation when stating. “You appear to be talking to someone I do not see.” Making observations involve verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse’s perceptions.
What is the most forgotten step of delegation?
Supervision & Evaluation
Infectious micro-organism in human blood that can cause disease in humans are called
Bloodborne pathogens
Therapeutic lithium range
What is 0.6 to 1.2mEq/L
A nurse is caring for a client that has an order for an insulin drip STAT. What kind of insulin can be safely administered intravenously? Select all that apply.
a. Lantus
b. Levemir
c. Regular
d. NPH
What is C?
Regular insulin is a short acting medication that begins working in about 30 minutes.
Which arterial blood gas (ABG) values would the nurse anticipate in the client with a bowel obstruction who has a nasogastric tube attached to continuous suction?
1. pH 7.25, Paco2 55, HCO3 24
2. pH 7.30, Paco2 38, HCO3 20
3. pH 7.48, Paco2 30, HCO3 23
4. pH 7.49, Paco2 38, HCO3 30
4. pH 7.49, Paco2 38, HCO3 30
Rationale: The anticipated ABG finding in the client with a nasogastric tube to continuous suction is metabolic alkalosis resulting from loss of acid.
Is one-on-one interaction between a nurse and another person that often occurs face to face.
What is Interpersonal Communication
It is the level most frequently used in nursing situations and lies at the heart of nursing practice.
What is second step of the delegation process?
Who-decide on the delegate.
A virus that attacks and destroys the infection-fighting cells of the immune system is called?
HIV
Potassium (K)
What is 3.5-5.5 mEq/L
An adolescent with Type I diabetes is evaluated in the ED for treatment of diabetic ketoacidosis. What assessment findings will the nurse expect to find?
What is a fruity breath odor and decreasing level of consciousness
DKA develops when a severe insulin deficiency occurs. Hypergylcemia occurs with DKA and include a fruity breath odor and decreased LOC. Hypotension occurs because of a decrease in blood volume due to the dehydrated state that occurs with DKA
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats/min. The nurse would assess the client for which effects of this cardiac occurrence? Select all that apply.
1. Dyspnea
2. Flat neck veins
3. Nausea and vomiting
4. Chest pain or discomfort
5. Hypotension and dizziness
6. Hypertension and headache
1. Dyspnea
4. Chest pain or discomfort
5. Hypotension and dizziness
Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats/min is at risk for low cardiac output caused by loss of atrial kick.
Effective health communication requires awareness of language, nonverbal communication, and respect for contextual and cultural influences.
What is Nurse-Community Relationships
Initiate restraints
What is RN?
A mother of a child with mumps calls the clinic to report that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?
To bring the child to the clinic to be seen by the pediatrician.
Mumps usually affect the salivary glands but can also affect multiple organs. The most common complication is septic meningitis. The virus is in the cerebrospinal fluid and s/s include nuchal rigidity, lethargy and vomiting.
The normal PT and INR rates
What is 11 to 12.5 seconds and 0.81 to 1.20
A client is admitted to a med-surg unit following a thyroidectomy. Which assessment is the priority for this client?
Audible stridor
The thyroid is located in the anterior neck. It is important to monitor the airway status as any swelling to the surgical site can cause respiratory distress.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
1. Loud wheezing
2. Wheezing on expiration
3. Noticeably diminished breath sounds
4. Increased displays of emotional apprehension
3. Noticeably diminished breath sounds
Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds.
Which statement about nonverbal communication is correct? 1. The nurse's verbal messages should be reinforced by nonverbal cues. 2. It is easy for a nurse to judge the meaning of a patient's facial expression. 3. The physical appearance of the nurse rarely influences nurse-patient interaction. 4. Words convey meanings that are usually more significant than nonverbal communication
The correct answer is 1 Awareness of the tone of verbal response and the nonverbal behavior results in further exploration.
What medication can a Nurse Tech/Intern administer?
What is none. They cannot administer medication by any route.
Applying the same infection control procedures on all clients is a practice known as
Standard Precautions
Magnesium (Mg)
What is 1.5-2.5 mEq/L
The nurse has an order to given insulin to a client with acute renal failure. Which of the following is the purpose of giving insulin in this situation?
a. To move glucose out of cells
b. To increase bloodstream sodium
c. To move potassium into cells
d. To reduce hyperglycemia
What is C?
Insulin administration in acute renal failure (ARF) helps to facilitate movement of potassium into the cells when potassium levels are dangerously high and dialysis is not immediately available. To prevent hypoglycemia for the client receiving insulin, IV glucose is also given.
A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding would the nurse identify as an early indication that the aneurysm has ruptured?
1. Widened pulse pressure
2. Unilateral motor weakness
3. Unilateral slowing of pupil response
4. A decline in the level of consciousness
4. A decline in the level of consciousness
Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.