Fundamentals CJE 2
A nurse in a health facility assesses a purchaser with elevated thirst, hunger, and urination. The
customers essential signs and symptoms are all inside everyday limits. Which urine specimens
the nurse request from the number one healthcare company based totally on the client, signs
and signs? - ANS-Urinalysis
A nurse is administrative enema when the purchaser reviews surprising, extreme stomach
cramping this is unrelieved by using slowing the infusion. What have to the nurse do next? -
ANS-Stop the infusion
A nurse is being concerned for a customer who is receiving NG tube feedings. Which findings
need to indicate to the nurse on the client isn't always tolerating the feedings? - ANS-6
unfastened stools in 24 hours
A nurse is caring for a customer with a prescription for full liquid weight-reduction plan. Which
food options are appropriate for this client? Select all. - ANS-Pudding
Ice cream
Fat loose broth
A nurse is worrying for a client with an indwelling urinary catheter. Which action must the nurse
perform to prevent infection? Select all. - ANS-Check the catheter tubing for kinks or twisting
Complete ordinary perineal care according to hospital coverage
A nurse is worrying for a purchaser with an order for what to dry gauze dressing. What is the
cause of this kind of dressing? - ANS-Facilitate the recuperation process
A nurse is being concerned for a purchaser with aspiration precautions. Which motion need to
the nurse take? Select all. - ANS-Assess the client's gag reflex prior to feed
Instructed patron to place the chin chest even as swallowing
Have a customer take a seat in a chair or at a 45 to 90°, if nevertheless in bed
A nurse is being concerned for consumer receiving continuous enteral feedings. Which motion
to the nurse prioritize whilst being concerned for a patron with non-stop enteral feedings? -
ANS-Maintain the pinnacle of the mattress at 30 to forty five° or higher
A nurse is being concerned for patron with an indwelling urinary catheter. Which movement
need to the nurse take when worrying for this patron? - ANS-Wear sterile gloves while
assessing the specimen port
, A nurse is caring for institution of customers. Which consumer has the lowest risk of aspiration?
- ANS-A purchaser who has a robust gag reflex
A nurse is educating the family of a consumer who could be on enteral feedings. Which
statement by using the member of the family suggests similarly training is needed? -
ANS-"Enteral feedings are started out whilst the gastrointestinal tract stops operating."
A nurse is feeding a consumer with dysphasia from a current stroke. Which action should the
nurse take to save you aspiration? - ANS-Instruct the purchaser to positioned their chin
downward whilst swallowing
A nurse is instructing a consumer approximately a way to do a guaiac fecal occult blood test.
Which declaration via the patron suggests a want for similarly schooling? - ANS-"I will drink
orange juice to get my each day vitamin C."
A nurse is planning take care of a patron with urinary retention associated with a urinary
obstruction. Which action should the nurse consist of inside the plan of care? Select all -
ANS-Assessed for bladder distention
Request an order for a bladder scan
Monitor consumption & output
A nurse is making plans training for a patron on offering urinary tract infections. Which records
should the nurse encompass? - ANS-Maintain proper perineal hygiene
A nurse is planning in hygiene care for an in cellular consumer. Which action ought to be
covered in the plan of care? - ANS-Allow the customer to take part as an awful lot as they're
able
A nurse is providing hygiene to a mobile client. Which motion have to the nurse take to provide
suitable hygiene care? - ANS-Clean hands, then movements to chest and trunk
A nurse observes an unlicensed assistive employees who's changing the linens of a mattress
occupied with the aid of a cellular customer. Which motion through the UAP required the nurse
to interfere? Select all. - ANS-Maintain the bed at a level below the waist while converting linens
Stretches over the mattress to straighten the outfitted sheet
Lower side rails on each facet facets of the mattress on the identical time
A nurse observes the urine picture in clients urinary catheter bag. Urine has an unsightly smell.
The nurse should recognize that those findings are related to sickness? - ANS-UTI
The consumer is scheduled to have a debridement of the pressure injury on their heel. When
planning care for this client, which action to the nurse take? - ANS-Administer the ordered
analgesic 30 minutes before the debridement
A nurse in a health facility assesses a purchaser with elevated thirst, hunger, and urination. The
customers essential signs and symptoms are all inside everyday limits. Which urine specimens
the nurse request from the number one healthcare company based totally on the client, signs
and signs? - ANS-Urinalysis
A nurse is administrative enema when the purchaser reviews surprising, extreme stomach
cramping this is unrelieved by using slowing the infusion. What have to the nurse do next? -
ANS-Stop the infusion
A nurse is being concerned for a customer who is receiving NG tube feedings. Which findings
need to indicate to the nurse on the client isn't always tolerating the feedings? - ANS-6
unfastened stools in 24 hours
A nurse is caring for a customer with a prescription for full liquid weight-reduction plan. Which
food options are appropriate for this client? Select all. - ANS-Pudding
Ice cream
Fat loose broth
A nurse is worrying for a client with an indwelling urinary catheter. Which action must the nurse
perform to prevent infection? Select all. - ANS-Check the catheter tubing for kinks or twisting
Complete ordinary perineal care according to hospital coverage
A nurse is worrying for a purchaser with an order for what to dry gauze dressing. What is the
cause of this kind of dressing? - ANS-Facilitate the recuperation process
A nurse is being concerned for a purchaser with aspiration precautions. Which motion need to
the nurse take? Select all. - ANS-Assess the client's gag reflex prior to feed
Instructed patron to place the chin chest even as swallowing
Have a customer take a seat in a chair or at a 45 to 90°, if nevertheless in bed
A nurse is being concerned for consumer receiving continuous enteral feedings. Which motion
to the nurse prioritize whilst being concerned for a patron with non-stop enteral feedings? -
ANS-Maintain the pinnacle of the mattress at 30 to forty five° or higher
A nurse is being concerned for patron with an indwelling urinary catheter. Which movement
need to the nurse take when worrying for this patron? - ANS-Wear sterile gloves while
assessing the specimen port
, A nurse is caring for institution of customers. Which consumer has the lowest risk of aspiration?
- ANS-A purchaser who has a robust gag reflex
A nurse is educating the family of a consumer who could be on enteral feedings. Which
statement by using the member of the family suggests similarly training is needed? -
ANS-"Enteral feedings are started out whilst the gastrointestinal tract stops operating."
A nurse is feeding a consumer with dysphasia from a current stroke. Which action should the
nurse take to save you aspiration? - ANS-Instruct the purchaser to positioned their chin
downward whilst swallowing
A nurse is instructing a consumer approximately a way to do a guaiac fecal occult blood test.
Which declaration via the patron suggests a want for similarly schooling? - ANS-"I will drink
orange juice to get my each day vitamin C."
A nurse is planning take care of a patron with urinary retention associated with a urinary
obstruction. Which action should the nurse consist of inside the plan of care? Select all -
ANS-Assessed for bladder distention
Request an order for a bladder scan
Monitor consumption & output
A nurse is making plans training for a patron on offering urinary tract infections. Which records
should the nurse encompass? - ANS-Maintain proper perineal hygiene
A nurse is planning in hygiene care for an in cellular consumer. Which action ought to be
covered in the plan of care? - ANS-Allow the customer to take part as an awful lot as they're
able
A nurse is providing hygiene to a mobile client. Which motion have to the nurse take to provide
suitable hygiene care? - ANS-Clean hands, then movements to chest and trunk
A nurse observes an unlicensed assistive employees who's changing the linens of a mattress
occupied with the aid of a cellular customer. Which motion through the UAP required the nurse
to interfere? Select all. - ANS-Maintain the bed at a level below the waist while converting linens
Stretches over the mattress to straighten the outfitted sheet
Lower side rails on each facet facets of the mattress on the identical time
A nurse observes the urine picture in clients urinary catheter bag. Urine has an unsightly smell.
The nurse should recognize that those findings are related to sickness? - ANS-UTI
The consumer is scheduled to have a debridement of the pressure injury on their heel. When
planning care for this client, which action to the nurse take? - ANS-Administer the ordered
analgesic 30 minutes before the debridement
