As an advocate for the client, the nurse must make sure that
As an advocate for the client, the nurse must make sure that “safe,… As an advocate for the client, the nurse must make sure that “safe, effective care” is provided within the confines of which of the following?A. National Council for Licensure ExaminationB. The Joint CommissionC. Nurse Practice Act (NPA)D. American Nursing Association (ANA) A nurse is caring for a client who is 24 hours postoperative following a total laryngectomy. Which nursing intervention is the highest priority for this client?A. Keep airway openB. Meet with a dietitianC. Maintain proper bowel eliminationD. Prevent pressure injuries from the stoma The nurse is evaluating a client’s wound drainage and finds the drainage is clear and watery. Which of the following best describes the drainage?A. Sanguineous drainageB. Serosanguineous drainageC. Purulent drainageD. Serous drainage A nurse is collecting data on a client who has been diagnosed with sepsis from wound infection, which of the following findings would be most concerning a, dry cough b, increased lethargy c, elevated blood pressure d, cloudy urineA client is recovering from surgery and is very restless. The client’s vital signs are as follows: HR 120 bpm, BP 70/52, with cool and clammy skin. What is the priority action?A. Check the client’s blood glucoseB. Continue to monitor the clientC. Notify the providerD. Obtain an EKGThe nurse recognizes the early signs and symptoms of septic shock as/a, blood pressure 144/90b, shallow breathing and elevated heart rate c, tachypnea, tachycardia, and low-grade feverd, pallor and cool skin A nurse is caring for a client TPN and is monitoring the blood glucose, what is the best response to the client who asks why their blood sugar is being monitored?a, we monitor everyone’s blood glucoseb, the TPN can cause your blood glucose to be high c, you should speak to your providerd, you are now a diabeticthe nurse is attending an in-service about infection control , which of the following statements by the nurse indicates an understanding of the teaching?A ,if i eat a nutritious diet, i will avoid infections B, vaccinations only prevent a disease from becoming severe C, antibiotics should always be started at the first sign of infection D, use of proper hand hygiene is an effective way to prevent the spread of infection The surgical team met with a client who will be undergoing elective surgery. Which team member is responsible for informed consent?A. The surgeonB. The nurseC. The anesthesiologistD. The social workerDuring the shift report the LPN states the post-operative client had bright red drainage on the dressing. What is another word for red drainage?A. SerosanguineousB. Serous drainageC. Sanguineous drainageD. Purulent drainage In the event of a wound evisceration, what should the nurse do first?A. Initiate a bolus of IV fluidsB. Cover the incision with a dressing moistened with sterile normal saline solutionC. Lower the client’s head and elevate the feetD. call the provider Which of the following postoperative instructions will help minimize the risk of postoperative DVT?A. Perform deep knee bends as soon as possibleB. Remain on bed rests as long as possibleC. Take a brisk walk in the hallwayD. Perform frequent ankle pumps QSEN recognizes that the use of the National Patient Safety Goals (NPSGs) places an additional focus on safety. How are the NPSGs determined and adjusted each year?A. The Board of Commissioners performs research and develops the NPSGsB. QSEN determines the NPSGsC. A panel of experts review the previous years’ sentinel events to determine updated goalsD. the world health organization reviews current literature and develops safety goals Which of the following food choices would be best when promoting a healthy immune system?A. Olive oil and peanutsB. Celery and waterC. Pasta and breadD. Eggs and Beans Which of the following describes the best time to apply anti embolism stockings?A. After bathing and applying powderB. Before retiring in the eveningC. Before rinsing in the morningD. With the client in a standing positionThe nurse is completing the preoperative checklist. Which of the following is not part of the preoperative checklist?A. Evaluate the allergiesB. Conducting the Time OutC. Ensuring that the history and physical examination is completedD. Informed consent is signed Wound care plays a large role in infection prevention. Which of the following is an example of an expected finding?A. Serous drainageB. Warm, tender skinC. Purulent drainageD. Red, hard skin A client is receiving a unit of packed red blood cells. The client’s baseline vital signs were as follows; BP 90/50 mm Hg, HR 100 bpm, RR 20 breaths/min, and Temp. 98 F. Vital signs obtained 15 minutes after the infusion is started reveal the following – the client’s BP is 92/54 mm Hg, HR 100 bpm, RR 18, and Temp. 101.4 F. Which should the nurse do first?A. stop the transfusion B. Offer the client a cool washclothC. Request an order for antibioticsD. Place the client in high fowler’s position Which IV therapy results in the greatest increase in oxygen-carrying capacity for a client with shock?A. Lactated ringer’s solutionB. HetastarchC. Packed Red Blood CellsD. FFP a client is sitting up in a chair and suddenly says, my incision just opened up, which of the following best describes this situation?A, evisceration B, extravasationC, dehiscence D, cellulitis Which of the following interventions will improve pulmonary function and decrease the risk of pneumonia? (Select all that apply)A. Repositioning every 3-4 hoursB. Use of an incentive spirometer device 10 times every 1-2 hours while awakeC. Early ambulationD. Resting quietly in bedE. Cough and deep breathing exercisesWhich of the following statements best describes the rationale for use of a client-controlled analgesia (PCA) pump?A. The client has a decreased risk of opioid dependencyB. A PCA is more cost effective than other optionsC. The client achieves a therapeutic level of analgesiaD. The family can assist in pain control client is scheduled for total knee replacement surgery. Which preoperative data finding is most important for the nurse to communicate to the surgical team before the procedure?A. The serum potassium level is 3.6 mEq/LB. The oxygen saturation is 97%C. The client is asking about postoperative wound careD. The client reports eating breakfast Giving a client a back rub is using which of the following pain control theories?A. DistractionB. Gate controlC. SynergismD. Guided imagery Which description illustrates the beginning of the postoperative period?A. Closure of the client’s surgical incisionB. Completion of the surgical procedure and arousal of the client from anesthesiaC. discharge planning initiated in the preoperative setting The nurse is instructing a client to use an incentive spirometer , the client demonstrates correctly if he/she performs the following actionInhales in short, quick breaths through the mouthpiece Blows into the mouthpieceInhales deeply through the mouthpiece and keeps the ball afloat Inhales deeply but not able to keep the ball afloatWhich of the following is considered an early sign of shock in an older adult client?A. Cool, clammy skinB. HypotensionC. RestlessnessD. Increased urinary output Which of the following are signs of fluid volume deficit?A. A pulse of 86 bpmB. Increasing restlessnessC. Blood pressure of 110/70 mm HgD. Hypoactive bowel sounds in all 4 quadrants Nurses collect all types of data using a variety of methods. A client describing their discomfort is considered what type of data?A. Subjective dataB. Objective dataC. Client dataD. Focused dataThe nurse is preparing to receive a client from surgery and is implementing deep vein thrombosis (DVT) prevention measures, which of the following statements is not correct in implementing DVT prevention a, the nurse will administer Enoxaparin subcutaneously daily per physicians’ orders b, the nurse will apply sequential compression devices only at bedtimec, the client will eat meals sitting up in the bedside chair d, the client will ambulate dailyA client newly diagnosed with deep vein thrombosis (DVT) of the left lower left extremity is on bed rest. Which of the following actions is the priority intervention for this client?A. Place pillows directly under the client’s left kneeB. Place the legs are in a dependent positionC. Massage the leg each shiftD. Elevate the left extremity Health Science Science Nursing NURSING NUR3643
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