Review Kaplan fundamentals ngn (2024)

The nurse is caring for a senior adult client with three diagnoses of Parkinson's disease and an exacerbation of COPD. The nurse observes the unlicensed assistant personnel (UAP) providing morning care and obtaining vital signs by using a portable electronic blood pressure cuff and clip-on pulse oximetry sensor.

Nurse's Notes: Vital Sign # 0715: Client sitting up in bed with oxygen 2.1 per nasal cannula (NC) on. Clear pink skin and warm and dry lungs with scattered wheezes throughout. The client complains of shortness of breath and states, "I feel so much better than I did a couple of days ago." Mild tremors were noted. The client states, "My hands shake all the time."

1140: Client is still in bed with oxygen 2.1 per NC on, scattered wheezes throughout, and coarse rhonchi, which are clear with coughing. Cough is productive of yellow phlegm. Skin cool and dry. The client complains of shortness of breath or discomfort and states, "I like to keep it chilly in my room to help me breathe."

1140: The UAP reports to the nurse that the client's SpO2 is decreased.

Q1. After assessing the patient and reviewing the vital signs, which nursing action is appropriate to address the decreased SpO2?

(Select all that apply.)

A. Verify the pulse oximeter is intact and properly applied. B. Verify the supplemental oxygen is turned on and functioning. C. Notify the physician immediately. D. Request a prescription for a breathing treatment. F. Assess the temperature of the client's hands. G. Increase the flow of oxygen to 3L per nasal cannula. H. Request an order for ABGs. I. Replace the bateries in the pulse oximeter. J. Obtain the SpO2 using the client's ear lobe.

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A. Inhales through the mouthpiece. B. Holds the mouthpiece with one hand. C. Takes a deep breath through the nose. D. Exhales after removing the mouthpiece.

An incentive spirometer is used to help improve lung function by encouraging deep breathing. The user should inhale through the mouthpiece, not through the nose. This observation indicates that additional teaching is required.

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A. Stand at the head of the bed and feed the client. B. Place a bib around the client's neck to protect clothing. C. Reschedule procedures to avoid interfering with meals. D. Instruct the client to complete one food container at a time.

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The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.

1635: Most recent entry from a visit to primary care provider 5 days ago. Vital signs were BP 164/90, HR 96, RR 20, T 96.7°F (35.9°C), and SpO2 96% on room air. Past Medical History (PMH) positive for osteoporosis, a history of ovarian cancer treated with a hysterectomy and chemotherapy 16 years ago, hypercholesterolemia, and hypertension being managed with diet and exercise. During this recent visit, the client was started on hydrochlorothiazide (HCTZ) 12.5 mg, 1 tablet PO every AM. No Known Drug Allergies (NKDA). Additional home medications include:

• Atorvastatin 20 mg PO, 1 tablet every PM
• Calcium 1000 mg, 1 tablet PO BID
• multi-vitamin, 1 capsule PO every AM

The nurse obtained the bloodwork, started the IV, and administered morphine IV push.

> Complete the following sentence:

The nurse's highest priority is planning care knowing that the client is at risk for seizures due to ______and _______.

Explanation

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The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.

The client was transferred to ED Bed 5 via stretcher. The client’s spouse is at the bedside. The client states "I feel so much better now except my wrist. It's really hurting." Advised to assess and then check with ED physician about something for the pain. VS BP 112/68 HR 99 RR 20. T 98.4° F (36.9° C). SpO2 96% on room air. The client is alert and oriented (A&O x 4), pleasant, and cooperative. PERRLA, skin intact with no bruising except for dorsal left forearm and wrist which is ecchymotic and edematous. Radial pulses are strong and equal (+3). Fingers warm with capillary refill - 3 sec. Lungs clear Abdomen soft with bowel sounds x 4 quadrants. Pedal pulse + x 4 and no pedal edema.

The client is being prepped for an open reduction internal fixation of the left wrist on the morning of day 2.

> Which three findings indicate that the client’s hemodynamic status has improved?

A. BP increased from 112/68 mm Hg to 122/80 mm Hg. B. Serum sodium decreased from 146 mEq/L (146 mmol/L) to 138 mEq/L (138 mmol/L). C. Serum potassium increased from 5 mEq/L (5 mmol/L) to 5.4 mEq/L (5.4 mmol/L). D. Urine output averaging 18 mL/hour. E. Bowel sounds in all four quadrants. F. Urine output averaging 45 mL/hour.

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A. Productive cough B. Heart rate 112 beats/min C. Blood pressure 96/52 mm Hg D. Weight gain of 2 kg (4.4 lb) E. Edema +2 of bilateral ankles and feet

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A. Keep the area open to air B. Cleanse with hydrogen peroxide daily C. Apply hydrocortisone cream to the area D. Keep the suture area covered with gauze

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A. Measures the size of the wound B. Cleans from bottom to top C. Works outward from the incision D. Wipes from clean area to less clean area E. Removes exudate with hydrogen peroxide

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A. Position the window of the toes B. Apply lotion to the client's lower legs C. Ask the client to lie supine in bed for 15 minutes D. Turn one stocking inside out before applying it to the heel

Before applying anti-embolism stockings, the nurse should ask the client to lie supine in bed for 15 minutes. This is because anti-embolism stockings should be applied with the client in a supine position ¹. This helps to promote blood return to the heart and decrease the risk of blood clots ¹.

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A. Coffee with cream and sugar B. Gelatin with applesauce C. White grape juice D. Bouillon that is reconstituted E. Tea with sugar F. Fruit flavored ice pop

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A. Suctioning must follow a set schedule every two hours B. Coughing helps loosen secretions before suctioning C. A strict sterile technique is always required for suctioning D. Suction pressure time and catheter size are critical

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A. Fraud B. Battery C. Assault D. Malpractice

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A. Assault B. Battery C. Malpractice D. Negligence

Assault is an intentional act that causes another person to be in fear of immediate harm ¹. In this case, the caregiver's threat to restrain the uncle if he doesn't calm down can be considered an assault because it puts the uncle in fear of immediate harm.

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A. Sits client on the side of the bed and assists the client to stand on right leg B. Rolls client to the right side and raises head to sit client on the side of the bed C. Lays client flat on the left side and has client stand at the side of the bed D. Stands client from the side of the bed on the left leg and pivots client to the chair

This is because the client has right-sided paralysis and will not be able to bear weight on their right leg. By standing on their left leg and pivoting to the chair, the client can safely transfer from the bed to the wheelchair with the assistance of the nurse.

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A. Bradycardia B. Hypertension C. Tachypnea D. Pyrexia

A rectal temperature should not be taken if the client has bradycardia because stimulation of the vagus nerve during the insertion of the rectal thermometer can result in a further decrease in heart rate. Hypertension, tachypnea, and pyrexia are not contraindications for taking a rectal temperature.

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A. Client demonstrates correct glucose testing. B. Client says 'I can do the testing now'. C. Client explains the testing process to the nurse. D. Client observes the nurse test glucose 5 times.

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A. Potential for falls B. Potential for injury C. Potential for loneliness D. Potential for self-neglect

The client's statement of avoiding people because of having scabies and difficulty walking indicates that the client may be experiencing social isolation and loneliness. Loneliness is a significant concern for clients as it can lead to depression, anxiety, and other negative health outcomes. The other options, such as the potential for falls, injury, and self-neglect, may also be concerns for the client but are not indicated as the greatest concern in this scenario based on the information provided. Therefore, the nurse should document the client's greatest concern as the potential for loneliness.

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A. Assesses the IV site for inflammation B. Measures the urine output for the day C. Calls the partner to come and visit D. Asks the client if pain medication is required

The client is likely feeling scared, vulnerable, and alone. By calling the partner to come and visit, the nurse can provide the client with emotional support and comfort during this difficult time. This can also help to alleviate the client's distress and promote a sense of security and familiarity.

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A. Glucose B. Cholesterol C. Hemoglobin D. Sedimentation rate

Total parenteral nutrition (TPN) is a form of nutrition that is administered intravenously when a client is unable to eat or absorb nutrients orally or enterally. TPN solutions contain a high concentration of glucose, which provides the body with energy. Therefore, the nurse must closely monitor the client's glucose levels, as TPN can cause hyperglycemia (high blood sugar levels).

Frequent monitoring of blood glucose levels is necessary to ensure that the client's blood sugar stays within an acceptable range. Hyperglycemia can lead to a variety of complications, including dehydration, electrolyte imbalances, and damage to organs such as the kidneys and eyes. If the client's blood glucose levels are consistently high, adjustments to the TPN solution may be necessary, or insulin may need to be administered to help regulate blood sugar levels.

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A. The nurse provides written and verbal instructions prior to discharge. When at home the client began to take the wrong medication. B. The nurse hangs a new bag of IV fluids 1 hour early and does not count what is remaining in the bag on the fluid record. C. The nurse gives medication to another nurse to give to a client and the wrong client receives the medication and becomes ill. D. A client becomes confused and combative and pulls out the IV. The nurse calls the health care provider to change the behavior.

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A. Advances catheter 2-3 inches (5 to 7.6 cm). B. Applies suction intermittently for 20 seconds. C. Moistens catheter prior to insertion. D. Uses non-dominant hand to manipulate catheter.

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A. Cover the exposed needle with an alcohol swab. B. Prepare another injection with a sterile syringe and needle. C. Hold the syringe upright to the client's bedside to provide the injection. D. Cleanse the needle cap with an alcohol swab before covering the needle.

Dropping the needle cap on the floor contaminates it, and any attempt to clean it with alcohol will not make it sterile again. Therefore, the only way to ensure that the injection will be sterile is to use a new sterile syringe and needle.

Holding the syringe upright or cleansing the contaminated needle cap with alcohol is not enough to ensure sterility and can put the patient at risk for infection.

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A. Presence of exudate B. A number of sutures C. Approximation of edges D. Time of last antibiotic E. Color of the wound bed

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A. Explain the procedure in detail before beginning B. Have the child blow on a pinwheel during insertion C. Insert the catheter about 5 cm D. Use a size 10 Fr catheter E. Insert 2% lidocaine lubricant into the meatus F. Use firm pressure if resistance is met

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A. Insert an indwelling urinary catheter B. Insert an intermittent urinary catheter C. Cleanse the urinary meatus and provide a sterile container D. Pour urine collected from a clean bedpan into a specimen cup

This is known as a clean-catch urine sample. The nurse cleanses the urinary meatus to reduce the chance of contamination from bacteria on the skin. The patient then collects a urine sample in a sterile container while voiding.

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