Term 1 of 78
A nurse is preparing to remove personal protective equipment (PPE) after irrigating a client's
wound infection and applying a fresh sterile dressing. Identify the sequence for removing PPE.
(Move the steps into the box on the right, placing them in the order of performance. Use all the
steps.)
Peppermint
The nurse should remind the client that foods that relax the esophageal sphincter and thus
worsen the manifestations of GERD include peppermint and spearmint. GERD is a condition
in which gastric acids and gastric contents reflux into the esophagus due to delayed
stomach emptying or relaxation of the lower esophageal sphincter.
The nurse should remove the most contaminated piece of PPE. the gloves, first, Next, the
nurse should remove the face shield and then the gown. The nurse should remove the least
contaminated piece of PPE, the mask or respirator, last.
Occupational therapist
The nurse should initiate a referral to an occupational therapist to assist the client who has
impaired function to gain the skills for ADLS, including using eating utensils.
Digoxin
The nurse should expect the provider to withhold digoxin when the client's potassium level
is low to decrease the client's risk of dysrhythrmias due to digoxin toxicity. Potassium assists
in displacing digoxin, because digoxin binds to potassiurm, and reduces the risk for digoxin
toxicity.
,Term 2 of 78
A nurse is assisting in the planning of a health education class for a group of older adult clients.
Which of the following recommendations should the nurse include?
Obtain a pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and is
generally given at or near the age of 65, One dose provides lifelong immunity
Pain radiating to the right shoulder
Pain radiating to the right shoulder is a common manifestation of acute cholecystitis due to
the contraction of the bile ducts of the gallbladder.
Muscle weakness
Furosemide is a loop diuretic, which is used to treat hypertension and edema. Furosemide
can cause excess excretion of potassium. The nurse should monitor the client for
manifestations of hypokalemia such as nausea, muscle weakness, and spasms.
Maintain the use of compression stockings except when bathing the client.
The antiembolic stockings should be removed for short periods (30 to 60 min) when
bathing
,Definition 3 of 78
Nonresponsive to commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose
state. The GCS is a standardized tool that allows for the evaluation of a client's level of
consciousness. The test is divided into three sections that evaluate eye opening, motor response,
and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low score of 3 (fully
comatose).
A nurse is collecting data from a client who was admitted with a Glasgow coma scale (GCS)
of 3. Which of the following findings should the nurse expect?
A nurse is contacting the provider of a client who has heart failure and a potassium level of
3.4 mEq/L. Which of the following client medications should the nurse expect the provider
to withhold?
A nurse is collecting data from a client who has diabetic ketoacidosis (DKA). Which of the
following findings should the nurse expect?
A nurse is collecting data from a client who has a new diagnosis of pheochromocytoma.
Which of the following findings should the nurse expect?
, Term 4 of 78
A nurse is assisting a client who is on bed rest to perform isometric exercises. which of the
following actions should the nurse take?
Instruct the client to tighten and then relax muscles repeatedly.
The nurse should instruct the client to perform isometric exercises by holding muscles tight
for 5 seconds and then relaxing them. This form of exercise inivolves static contraction of a
muscle without any movement of the Joint, Immobility can cause systemic physiologic
effects such as increased heart rate, increased bone demineralization, decreased muscle
strength, joint contractures, and activity intolerance. Isometric exercises increase muscle
mass, tone, and strength while promoting circulation.
Skin flap of the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is that the skin flap of the residual limb is cool to the touch. The
nurse should immediately report this finding to the provider. The skin flap of the residual
limb should be warm to the touch, indicating adequate tissue perfusion.
Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to
pass if cramping occurs during administration of the enema. Lowering the helght of the
enema bag will decrease the rate the fluid enters the bowel. Tap water enemas consist of
500 ml to 1Lof fluid that is instilled into the bowel to soften feces. The volume of fluid
stimulates peristalsis.
I will flex at the knees and use my leg muscle to lift an object off the floor.
The nurse should review bending and lifting restrictions with the client who has had a
laminectomy. Bending at the waist is not permitted. The client should be instructed to flex
at the knees and use their leg muscles to decrease the risk of back injury when lifting an
object off the floor. Weight limits should also be reinforced; following a laminectomy, a
weight restriction of 4,5 kg (10 Ib) is prescribed.
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