NURS 235 Capstone fundamentals- University Of Charleston

NURS 235 Capstone fundamentals- University Of Charleston a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse use? behavioral indicators (increased agitation, restlessness) a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should the nurse do first? recheck the clients BP (reassess prior to any intervention) a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify as a cath occlusion? bladder distention (inability to empty the bladder, impaired elimination) a nurse is discussing immunity with a client who has received an immunization, the nurse should identify that an immunization functions as part of which of the following types of immunity? acquired immunity (artificial/acquired immunity occurs when antigens from toxoids or immunizations are ADMINISTERED to a client, once in the body, the stimulate the production of antibodies) a nurse is reviewing the health history of an OA who has a hip fracture the nurse should identify what is a risk of developing pressure injuries? urinary incontinence (r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction and shear, immobility, alterations in sensory perception) a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red and there is warmth along the coarse of the vein, what should the nurse do? d/c the infusion (assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start new IV) a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding? macule (nonpalpable smaller than 1cm, ex: freckle) a community health nurse is teaching a group of clients about first aid for different types of wounds. which of the following client statements indicates an understanding of the teaching? i should apply clean dressings over the top of blood saturated dressings and hold pressure (to prevent disruption of wound tissue) a nurse is sitting with the partner of a client who recently died. which of the following actions should the nurse take to facilitate mourning? encourage the partner to ask for help when needed a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which of the following behaviors should the nurse identify as increasing the client's risk for constipation? urge suppression history of chronic stimulant laxative use inadequate fluid intake a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the nurse do? ask the client to describe feelings a nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. which of the following actions should the nurse take to prevent contamination during the dressing change? restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray (if liquid comes in contact with the sterile field at any point it is considered contaminated and unsterile) a nurse is caring for a pt who is scheduled for a cataract surgery, the client states "is see just fine and have decided to cancel my surgery". which of the following responses should the nurse make? share with me more about the thoughts that are concerning you a nurse is teaching a client about the use of a MDI, which instruction should the nurse include in the teaching? inhale the medication deeply for 3-5seconds (hold breath for 10s after inhalation, shake MDI vigorously, hold mouthpiece 2.5-5cm/1-2in in front of mouth) a nurse is teaching a group of AP about the expected integumentary changes in OA, which should the nurse include decrease in elasticity (increase in pigmentation, decrease in subq and moisture levels) a nurse is monitoring a client who has been receiving intermittent enteral feedings, what should the nurse identify as an intolerance to the feeding? nausea (vomiting, dumping syndrome-change the rate or type of formula) a nurse enters a clients room and sees smoke coming from the trash can. which of the following actions should the nurse take first evacuate the room (RACE) a nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery, which of the following statements should the nurse make? the surgeon will answer your questions before surgery a nurse is reviewing info about advance directives with a newly admitted client. which of the following statements by the client indicates an understanding of the teaching? i have a living will that outlines my wishes when i am unable to make a decision a nurse is admitting a client who has meningococal meningitis, what should the nurse do first? initiate droplet precaution (put in private room and wear surgical mask within 3ft) a nurse finds a client on the floor of their room experiencing a seizure, which of the following actions is the nurse's priority place the client on their sided with their head forward (ABC) a nurse is providing discharge teaching to a client who has a prescription for home O2, which info should the nurse teach? wear cotton socks when the O2 is in use (other fabrics cause static) . . . . . . . .