HURST Review Elevate Q-Card - Questions, Answered and well detailed Rationales
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HURST Elevate Q-Card
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HURST Elevate Q-Card
HURST Review Elevate Q-Card - Questions, Answered and well detailed Rationales An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the RN to provide to the UAP? 1. "Notify me if the pulse oximetry reading dr...
an unlicensed assistive personnel uap has been assigned to take vital signs on several clients which instruction would be most important for the rn to provide to the uap
HURST Review Elevate Q -Card An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the RN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker with a fixed rate of 70 beats/minute. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher." 4. Correct: A temperature of 101. 5 degrees F (38.6 degrees C) or higher is reported to the primary healthcare provider. The client is likely to need cultures and antibiotic therapy. 1. Incorrect: The client with emphysema will likely have a pulse oximetry reading less than 95%. This is n ot the most important instruction to give the UAP. 2. Incorrect: This client is likely experiencing orthostatic hypotension, so is unstable. This task should not be assigned to the UAP. The RN should perform this task. 3. Incorrect: The nurse should worr y if the heart rate drops below the set pacemaker rate. It is normal for the rate to be greater than the fixed rate, but should never drop below the fixed rate. The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on str onger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg. 2. Correct: Place the cane on the stronger side of the body. The cane is placed for ward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require inte rvention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed. 2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could injury the UAPs back. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury. Which action would the nurse need to perform to increase stability while initiating a client t ransfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly. 3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the le gs to the width of the shoulders. 1. Incorrect: Do not use your back to do heavy lifting. They are not your strongest muscles. Use your legs. 2. Incorrect: A back belt will not increase the base of support. 4. Incorrect: The nurse should not lean forwar d or backward. The ears, shoulders, hips and feet should be aligned. A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110 -115°F (43 -46°C). 4. Uses long, firm strokes to wash from wrist to sho ulder of each arm. 5. Performs a back massage after completing the bath. 1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side r ail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C ) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation b y increasing venous blood return. 5. Incorrect: A back massage is appropriate after a bath and does not require nursing intervention. A back massage is a way of providing relaxation for the client. The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension posi tion. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward. 4. Correct: The left shoulder should be adducted. The position of adducting the shoulder forward promotes improved chest expansion and decreases str ain on the shoulder. 1. Incorrect: The right leg is positioned forward in the left lateral position. For the right lateral position, the left leg is positioned on a pillow in front of the right leg. 2. Incorrect: Both legs should not be extended for the right lateral position. The left leg should be positioned forward with the knee flexed to decrease the internal rotation of the femur. 3. Incorrect: Inversion of the feet is described as positioning the ankles toward the midline of the body. The feet shou ld be positioned in the neutral position to maintain proper ankle alignment. A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eyelids as prescribed. 5. Protect the eyes with a protective shield. 6. Mon itor eyes for redness and exudate. 1., 3., 4., 5., & 6. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions prevent infection, keep eyes moist, and protect the eye from injury. 2. Incorrect: Clean the eye s with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct. A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What p oints should the nurse include to help the clients control symptom flare -ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of y our diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber. 1., 3. & 4. Correct: If you are constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts. 2. Incorrect: Avoid meals that over -stimulate the gut, like large meals or high fat foods. 5. Incorrect: Broccoli and cabbage are common gas -producing foods that can cause abdominal distention and flatulence. A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, th e nurse is most concerned when the
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