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NUR 209 EXAM 2 ( IV AND VITALS!!) LATEST ALREADY ANSWERED A GRADED
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NUR 209 EXAM 2 ( IV AND VITALS!!) LATEST ALREADY ANSWERED A GRADED
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NUR 209 Final Exam Prep U LATEST ALREADY ANSWERED A GRADED Droplet precautions - ans--Use these for patients with an infection that is spread by large -particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Use a private room, if available. -Door may remai n open. -Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. -Transport patient out of room only when necessary and place a surgical mask on the patient if possible -Keep visitors 3 ft from the infected person airborne precautions - ans---Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). -Place patient in a pr ivate room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside, or monitored filtration if air is recirculated. Keep door closed and patient in room. -Wear a resp irator when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases. -Transport patient out of room only when necessary and place a surgical mask on the patient if possible. -Consult CDC guidelines for additional prevention strategies for tuberculosis. contact precautions - ans---Use these for patients who are infected or co lonized by a multidrug -resistant organism (MDRO). -Place the patient in a private room, if available. -Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's e nvironment. -Change gloves after having contact with infective material. -Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. -Limit movement of the patient out of the room.Avoid sharing pa tient-care equipment The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. A newborn who has hypothermia A child who h as pneumonia An older adult who is post MI (heart attack) A teenager who has leukemia A patient receiving erythropoietin to replace red blood cells An adult patient who is newly diagnosed with pancreatitis - ans--A newborn who has hypothermia, An older adu lt who is post MI (heart attack)A teenager who has leukemia, A patient receiving erythropoietin to replace red blood cells -Explanation: The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post -MI should n ot have a rectal temperature taken.** Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts. A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. An increase in the pulse rate A decrease in body temperature A decrease in blood pressure An increase in respiratory depth An increase in respiratory rate An increase in body temperature - ans--An increase in the pulse rate, An increase in respiratory rate -Explanation: The pulse often increases when a person is experiencing pain. Pai n does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth. The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply Blood pressure decreases with age. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause. Blood pre ssure decreases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent in African Americans. - ans--Blood pressure is usually lowest on arising in the morning, Women usually have lowe r blood pressure than men until menopause, Blood pressure tends to be lower in the prone or supine position, Increased blood pressure is more prevalent in African Americans. -Explanation: Blood pressure increases with age due to a decreased elasticity of t he arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women. Which actions should the nurse take before making an entry in a client's record? Select all that apply. - ans--The nurse should revi ew the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rathe r than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to. A nurse working in a community clinic assists middle -age clients to follow guidelines for health -related screenings and immunizations. What preventive measures would the nurse recommend for this popul ation? Select all that apply. - ans--The nurse would recommend several different preventive measure that are listed. The nurse would recommend that the client have a physical exam every year from age 40 on; that the female client do a breast self -examinati on every month; a pelvic examination and Pap test at least every 3 years for women; a prostate -specific antigen (PSA) test every year for men; and a Zoster vaccine live vaccination for adults 50 years and older. The nurse would recommend a clinical skin ex amination every year. An older adult client comes to the senior center for a check -up. During the visit, the client tells the nurse that he knows he should be more active than he is. The nurse reinforces the client's statement, explaining that physical ac tivity helps to lower the risk of which condition? Select all that apply. - ans--Physical activity is good for all people including the older adult. Being physically active (1) lowers the risk of heart disease, stroke, and diabetes, (2) reduces depression symptoms, and (3) improves thinking (Health People 2020). Staying active will increase or maintain strength and balance, allowing for continued independence and the prevention of injuries. Activity may be used to address symptoms of anxiety but it will not help lower the risk for anxiety. Arthritis can interfere with the older adult's ability to engage in physical activity. The nurse is planning an educational event for a group of senior citizens on the topic of the normal signs of aging. Which topic(s) sh ould the nurse include about healthy activities a person can engage in to prevent the problems associated with aging? Select all that apply. - ans--Physiologic changes and an increased incidence of chronic illnesses place older adults at greater risk for d eclines in health and quality of life. Health promotion strategies (good lifestyle habits) and health maintenance (disease prevention and treatment) afford even the oldest adult an advantage in maintaining optimal health. Exercise, not necessarily vigorous aerobic, is an example of a good lifestyle habit. Taking all medications as prescribed is an example of health maintenance. Vitamins and supplements should only be taken under the supervision of a health care provider. Maintaining friends and social activ ities have been noted as improving overall health in older adults as it prevents loneliness and "hibernation" type activities. The nurse is assessing a middle -aged adult age 48 years in the clinic. The nurse recalls the changes that occur in middle age as they complete the physical and cognitive examination. Changes that occur include what? Cardiac output decreases. Loss of fatty tissue Low-pitched sounds are more difficult. Visual acuity changes with myopia. - ans--Cardiac output decreases -Explanation: Middle age changes include the following: redistribution of fatty tissue around the middle and abdomen; drier skin; wrinkles dev elop; hair grays and men may experience baldness; cardiac output decreases; near -vision diminishes; presbyopia; hearing diminishes, especially high -pitched sounds; hormone levels decrease; calcium loss from bone occurs; decrease in muscle strength. The nu rse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearin g. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, wil l include which instructions? Select all that apply. - ans--Gradually increase activities as tolerated, Increased stress may interfere with recovery. Do not use the salt shaker at meals. -Explanation: Promoting health for older adults includes ensuring ade quate nutrition (e.g., low -fat diet, other diet modifications); balancing calories and activities; planning exercise as a daily activity; and educating the client that illness is a physical and emotional stress and increases the risk for complications. Tak ing naps will interfere with sleep at night. A healthy 52 -year-old client asks the nurse what she can do to maintain her health. Which of the following does the nurse recommend? - ans--Perform self -examination of the skin every monthThe benefits of buying summaries with Stuvia:
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