West Coast University :NURS 100 Fundamentals for Nurses week 2 Assignments ,100% CORRECT

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West Coast University :NURS 100 Fundamentals for Nurses week 2 Assignments 1. The patient's record shows that the pulse is 88 beats per minute, +3. The nurse described this finding as a pulse. a. B... ounding ℹ A bounding pulse is a pulse that feels as though your heart is pounding or racing. Your pulse will probably feel strong and powerful if you have a bounding pulse. Your doctor might refer to your bounding pulse as heart palpitations, which is a term used to describe abnormal fluttering or pounding of the heart. 2. Which of the following is a guideline in performing skin assessments on clients? a. a. Use standard terminology to report and record findings. ℹ Use standardized terminology to report and record findings. 3. The client states, “I have had difficulty urinating for the past 2 days and when I urinate there is a burning sensation.” What type of assessment should be done to assist the patient on their exact concern? a. Focused ℹ A focused assessment is conducted to assess a specific problem. In this case, the nurse would ask the patient about urinary frequency, bowel movements, and diet, and then take vital signs and assess the abdomen. Comprehensive assessments include a detailed health history and physical assessment. And emergency assessments are carried out in emergency situations (such as prior to CPR). 4. You are caring for a client who is incontinent and is not aware if incontinence occurs. Which of the following nursing actions should be taken? a. a. Immediately wash the skin with gentle soap and water after each incontinence. ℹ Immediately wash the skin with gentle soap and water after each incontinence prevents skin breakdown. 5. The admitting diagnosis of a client was respiratory infection. Sputum culture result is positive for M.R.S.A. What appropriate precaution should be initiated by the nurse? a. b. Contact isolation + wearing a mask. ℹ Remember that the precaution for M.R.S.A. is contact and wearing a mask should be added because the infected is the respiratory system. 6. What should be the guidelines you should follow when performing perineal care? a. a. For all patients, wash the groin area with a small amount of soap and water, then rinse. ℹ When doing perineal care, do not forget to clean the groin area for all patients, wash the groin area with a small amount of soap and water, then rinse. 7. The nurse is caring for a client with lightheadedness when standing. As a nurse the appropriate nurse action you should take is? a. b. Place the call bell within reach and instruct the patient to call for assistance before getting out of bed. ℹ Place the call bell within reach and instruct the patient to call for assistance before getting out of bed to prevent fall and accidents. 8. The A.P. is to perform oral care to a client. Which of the following actions should the nurse take? a. a. Assess client for aspiration risk. ℹ Clients should be assessed for risk of aspiration to prevent aspiration and other problems that might happen. 9. Which Cranial Nerve is being assessed when the patient is asked to shrug their shoulders and turn their head against resistance? a. Cranial nerve XI ℹ Spinal accessory nerve is checked on cranial nerve XI innervates the two muscles, sternocleidomastoid and trapezius. 10. The client had a sudden confusion and to evaluate the client's mentation we should use -ended questions. a. Open ℹ When obtaining a nursing history, use the open-ended question technique to allow the patient a wide range of possible responses. It allows patients to express what they understand to be true, yet is specific enough to prevent digressing from the issue at hand. It encourages free verbalization. The greatest advantage of this technique is that it prevents the patient from giving a simple yes or no answer that has the effect of limiting the patient’s response. 11. When a nurse receives a change-of-shift report, which of the following activities should be done first? a. c. Collect and organize patient data. ℹ The steps in the nursing process include assessment, analysis/diagnosis, planning, implementation and evaluation. The nurse should first collect client data, and then critically analyze the data to determine the clients’ priorities. This is followed by the nurse planning client-centered, measurable and realistic goals. The nurse implements care, which involves putting the plan into action, followed by evaluation to determine the effectiveness of the interventions. 12. The cleansing agent for hand washing the nurse should use if taking care of clients with Clostridium difficile should be soap. a. Non-antimicrobial ℹ The Centers for Disease Control recommends that hands should be washed with nonantimicrobial soap and water if in contact with spore-forming organisms such as Clostridium difficile or Bacillus anthracis. Proper hand hygiene includes using soapy lather and friction under running water for at least 15 seconds. 13. The nurse is providing perineal care for a female client understands the technique is to wipe from . a. Front to back ℹ Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. 14. A patient is recovering from a myocardial infarction. The nurse instructs an unlicensed assistive personnel that this patient needs a complete bed bath. Which of the following UAP's action should the nurse intervene on? a. B. Asking the patient to wash his chest. ℹ A complete bed bath is for clients who are totally dependent and require total hygiene care. Total care may be necessary for a client recovering from a myocardial infarction as a means of conserving client energy and reducing oxygen requirements. The nurse would intervene if the U.A.P. asked the client to wash himself. 15. When deciding whether to use a mechanical assistive device to transfer a patient, what criteria should the nurse consider? a. C. Ability of the client to patient. ℹ When deciding whether a mechanized assistive device should be used for a client transfer, the nurse looks at several factors. The most important consideration is whether the client can safely assist with the transfer. 16. What is the best site to examine to identify cyanosis in a dark-skinned patient? a. C. Conjunctivae. ℹ To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, palms, conjunctivae, lips, tongue, and mucous membranes. 17. What is the best site to examine to identify cyanosis in a dark-skinned patient? a. c. Lips and tongue. ℹ To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, palms, conjunctivae, lips, tongue, and mucous membranes. 18. A patient tested positive for human immunodeficiency virus (H.I.V.). What type of precautions should the nurse observe to prevent the transmission of this disease? a. Standard precautions ℹ Standard precautions are indicated for prevention of transmission of H.I.V. to health care workers. H.I.V. is not transmitted by casual contact or respiratory droplets. H.I.V. may be transmitted through sexual intercourse with an infected partner, exposure to H.I.V. infected blood or blood products, and perinatal transmission during pregnancy, at delivery, or through breastfeeding. 19. A nurse teaches a patient how to cope with chronic pain by using visualization. What stage of the nursing process is this? a. Implementation ℹ Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. 20. Upon auscultation, the nurse described the patient’s breath sounds as bubbling or popping sound. This breath sounds is classified as . a. Adventitious ℹ Bronchial, bronchovesicular, and vesicular breath sounds are normal breath sounds. Adventitious breath sounds refer to sounds that are heard in addition to the expected breath sound. Adventitious breath sounds are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways. The most commonly heard adventitious sounds include crackles, rhonchi, and wheezes. 21. A nurse used her hands to assess the patients skin temperature, turgor, and texture. This method of examination is called . a. Palpation ℹ Palpation is a method of feeling with the fingers or hands during a physical examination. Palpation uses the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body. 22. Which method of examination is being used when the nurse taps on body parts using the fingertips to determine the size, consistency, and borders of body organs, or the presence or absence of fluid in the body cavities? a. Percussion ℹ Percussion is a method of tapping body parts with fingers, hands, or small instruments as part of a physical examination. It is done to determine the size, consistency, borders of body organs and the presence or absence of fluid in body areas. 23. What adventitious breath sound would you hear with asthma? a. Wheeze ℹ Wheezing is a common symptom of conditions that narrow the small airways in the lungs, such as asthma and C.O.P.D. Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope. 24. A nurse is preparing for a bedridden patient’s oral care. The nurse should place the patient on his before starting the oral care. a. Side ℹ For bedridden patients, it is appropriate to place the client on his side to prevent aspiration. 25. While assessing an older adult client, the nurse detects a bruit over the right carotid artery. What method of examination was used by the nurse to identify bruit? a. Auscultation ? Hint: Bruit is an abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery. ℹ Bruit is an abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery. It can be heard on auscultation. The bruit may be heard ("auscultated") by securely placing the head of a stethoscope to the skin over the turbulent flow, and listening. 26. The nurse is making her rounds when she notices there’s smoke coming out of the patient’s room. The nurse observed the patient’s sleeping and was unaware of the smoke coming out from the room. Which is the highest priority of the nurse? a. c. Remove the patient from the room then activate the fire alarm. ℹ The nursing priority when there is fire is to do Rescue, Alarm, Confine and Extinguish. 27. Before beginning the physical examination, make sure you knock on the patient's door and identify yourself before entering. Be sure to obtain permission before entering the patient's room. This maintains the patient's right to . #2 - Closing doors and curtains shows respect for the patient’s . a. Privacy ℹ Showing respect to the patient by being sensitive to the patient's privacy needs is a very important responsibility of the nurse. Before beginning the physical examination, the nurse must close the door, draw the curtains, and drape the patient appropriately. 28. The nurse is doing health education to adolescent male clients regarding Testicular Self-examination. Which of the following the nurse should plan to include in the teaching? a. a. Examine the testicles after a bath or shower. ℹ The nurse should inform the adolescents to perform testicular self-examinations when the scrotal skin is relaxed. Testicular self examination is recommended to be made once a month. 29. The nurse is teaching a group of assisted-living residents about fall prevention. Which of the following statements indicates the understanding of the residents from the teaching? a. a. "It is a good idea to use the handrails in the bathroom." ℹ Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions. 30. Which of the following are the nursing actions during a client's seizure? a. a. Loosen restrictive clothing, place a pillow under client's head and place client’s head on the side. ℹ Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The nurse should assist the client who is having a seizure into a lateral position. This position assists with the drainage of saliva and mucus, preventing aspiration, and allows the tongue to fall forward, preventing airway obstruction. The nurse should place a pillow or rolled blanket under the client's head to protect the head from injury. The nurse should guide the client's movements to prevent injury. 31. The nurse is caring for a client who is confused and keeps on pulling the I.V. catheter. Which of the following should the nurse consider to use? a. c. Place mitten restraints on the client’s hands. ℹ The nurse should consider placing mitten restraints on the client’s hands to prevent pulling out the IV catheter. The nurse should obtain a prescription from the provider to apply these restraints. 32. A testicular self-examination or T.S.E. should be performed monthly. Select which is the correct guideline in doing a T.S.E: a. a. Ensure that the scrotum is warm and relaxed. ℹ The nurse should inform the adolescents to perform testicular self-examinations when the scrotal skin is relaxed. T.S.E. is recommended after a shower or bath. Testicular self examination is recommended to be made once a month. 33. Which of the following illustrates fall prevention and promote safety for the assisted-living residents? a. a. A wall mounted handrails in the bathroom. ℹ Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions. 34. For perineal care of both women and men, always proceed from the contaminated area to the contaminated area. a. Least, most ℹ When doing perineal care, always proceed from the least contaminated area to the most contaminated area. Do not forget to clean the groin area for all patients, wash the groin area with a small amount of soap and water, then rinse. 35. The nurse is to perform oral care for a client. Which of the following actions is a priority for the nurse check? a. a. Gag reflex. ℹ Clients should be assessed for risk of aspiration to prevent aspiration and other problems that might happen. Gag reflex is a good indicator to assess the patient's risk for aspiration. 36. The nurse is caring for a client who is confused and keeps on pulling the I.V. catheter. A restraint is used to prevent tubes, lines, and catheters from becoming dislodged. It is considered to be the least restrictive method of restraint. a. Mitten ℹ The nurse should consider placing mitten restraints on the client’s hands to prevent pulling out the IV catheter. The nurse should obtain a prescription from the provider to apply these restraints. 37. You are caring for a client with urinary incontinence. Which of the following nursing actions would be inappropriate? 38. A nurse teaches a patient to try drinking warm milk before bedtime to promote better sleep. What stage of the nursing process is this? a. Implementation ℹ Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. 39. [Show More]

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