WGU CASAL 1 questions and answers well illustrated.

WGU CASAL 1 questions and answers well illustrated. what supplies should not be used during trach care - correct n balls what is the purpose of the nurse being a witness to consent - correct make sure the signature on the consent form belongs to the client BP readings for patient with hypertension should be done... - correct the same conditions (same place and position) steps of abdominal assessment - correct ction auscultation percussion palpation most important aspect of hand hygiene - correct ion primary prevention includes - correct nation of the exposure what should you do if the reliability of monitoring equipment is questioned - correct manual monitoring (esp for BP) and remove malfunctioning equipment physical exam on a toddler - correct the most distressing part of the exam last body mechanics for making an occupied bed - correct bed in high horizontal position where should the nurse place a stethoscope to listen to the aortic valve - correct answers.2nd intercostal space to the right of the sternum patient concerned about getting an infection from a blood transfusion - correct nt can donate autologous blood prior to surgery colorectal cancer screening - correct occult blood test every year screening for patients at average risk starts at age 50 what do you do if patient with nasal cannula has difficulty breathing - correct t to upright position what do you do prior to liquid medication administration - correct the liquid to make sure its properly mixed how to improve self-feeding for a patient with vision loss - correct ge food in clock pattern exercises for patient at risk of osteoporosis - correct t bearing exercises such as walking briskly position for incentive spirometer use - correct -fowler's procedure for 24 hour urine collection - correct rd first void and save all voids after contradictions for herpes zoster and other skin infections - correct ncture can increase risk of infection steps in assisting client from bed to chair - correct answers.1. ask if patient can bear weight 2. put chair on strong side of body 3. have client sit and dangle feet 4. use the stand-and-pivot technique to move the client to the chair mixing insulin - correct in NPH air in regular withdrawal regular withdrawal NPH aid for position changes for patient with LE weakness - correct ze bar infiltration of IV - correct blanching, edema, coolness phlebitis of IV - correct line, warmth cane use - correct cane on stronger side of the body top of cane parallel to greater trochanter advance cane 6-12 inches at a time move weaker leg forward with the cane food not on mechanical soft diet - correct eggs (eggs can be poached or scrambled) advanced directives - correct ate form of treatment client is willing to accept in the case of a serious illness indication client on bed rest has developed thrombophlebitis - correct ing, redness, tenderness and swelling of calf describe quality of pain - correct the pain feels to the patient, such as dull ache ear medication administration - correct up and out, press gently on the tragus check patient with visual impairments for these things to prevent fall - correct clarity, visual fields, visual acuity if client is angry about a diagnosis - correct ure client this is a normal phase of grief what do you do when inserting a peripheral IV - correct the arm in a dependent position patient with latex allergy - correct monitoring cords in sockinette and tape them NG tube insertion - correct at 90°, take sips of water, if patient gags or chokes do not remove tube just pull back slightly interventions for patient with purulent drainage - correct wound infection that requires contact precautions antiembolic stocking interventions - correct e antiembolic stockings at least once per shift to assess circulation and skin integrity bed position for enteral feedings - correct answers.HOB at 30° priority intervention for older adult receiving IV fluids - correct or lung sounds which can indicate FVE abnormal sounds in the carotid arteries - correct s which means narrowing of the arterial lumen what finding is a major concern in patient who has V/D for the past 3 days - correct cardia because it can indicate FVD irrigating an indwelling catheter - correct act the amount of irrigant used from the client's urine output procedure within RN scope of practice - correct ate enteral feedings tracheostomy suctioning - correct ter half the size of the lumen 100% O2 before suctioning lubricate end of catheter in sterile water or 0.9% NaCl adjust suctioning to 120 mm Hg and no more than 150 mm Hg romberg's test - correct identify alterations in balance and has the patient stand with arms at side and feet together contact precaution diseases - correct answers.MRSA VRE RSV C. diff Scabies Ebola droplet precaution diseases - correct answers.Meningitis Flu Rubella Pertussis (whopping cough) Mumps Ebola airborne precaution diseases - correct answers.TB Varicella (chicken pox) Measles vector precaution diseases - correct answers.Lyme's Disease Malaria protective environment used for who - correct e system compromises weighing patient with FVE - correct time every day - in the morning on arising same clothes same scale balanced daily foods to offer patient with dysphagia - correct or sour foods because they increase saliva production which helps with chewing and swallowing when can you remove an NG tube - correct there are bowel sounds and passing of flatus the client can have the tube removed and start on a clear liquid diet then progress to a regular diet what type of patient do you assess for oxygen toxicity while on oxygen therapy - correct nt on 100% oxygen via partial rebreather mask when can oxygen toxicity occur - correct n concentrations above 50% for longer than 24-48 hrs when are tube feedings prescribed - correct patient is unable to eat by mouth before starting patient on any diet (giving any food or liquid), what must the nurse do - correct n to bowel sounds because must have bowel sounds before they can eat or drink anything where should the nurse tape a catheter on a male to prevent pressure on the urethra at the penoscrotal junction - correct abdomen or inner aspect of thigh what nursing action prevents injury to client's eye when giving eye drops - correct the tip above the eye, never let it touch the eye irrigating ostomy - correct ating solution max of 20 inches above stoma use lukewarm tap water insert lubricated cone tip into ostomy stoma up to 1,000 mL can be used for irrigation communicating with hearing impaired patient - correct the client and speak slowly type of enema given before digital removal of fecal mass - correct retention enema what observation should be reported when changing wound dressing - correct answers.a halo of erythema on the surrounding skin which may indicate an underlying infection