exam one questions chapters 1-12 PDF

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Orthostatic hypotension occurs when there is a variation in the blood pressure from lying to sitting to standing. This variation can cause the client to become lightheaded and dizzy. The pulse deficit is the difference between a client's radial and apical pulse rates. Pulse deficits often reflect abnormal heart rhythms. The difference between the systolic and diastolic pressures is the pulse pressure. If the client's blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse pressure can be a predictor of heart conditions, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis. The auscultatory gap is a phenomenon that is most common with clients who have hypertension. It is a temporary disappearance of sound, usually between the first and second Korotkoff sounds. If the nurse does not inflate the blood pressure cuff enough to hear the systolic pressure as they begin to deflate it, an auscultatory gap could lead to an underestimation of systolic pressure or an overestimation of diastolic pressure. Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath, or dyspnea. Without intervention, this can become a life-threatening situation. A radial pulse of 45 beats/30 seconds translates to 90/min for documentation purposes. While the nurse should assess a pulse this rapid for a full minute, 90/min is still within the expected reference range of 60 to 100/min for an adult client and does not require immediate attention.

While a BP of 148/88 mm Hg is above the expected reference range of 120/80 mm Hg for an adult client, there is another finding that is priority for the nurse to report to the provider. The nurse can determine the depth of respiration subjectively by evaluating how much chest-wall movement is observed. The movement is generated by the movements of the diaphragm and intercostal muscles as the client breathes. With shallow respiration, the nurse will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible. A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound. Using the wrong cuff size for the client will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high and using a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder, which is inside the cuff, should surround 80% of the arm circumference. Blood pressure can vary considerably with the time of day. This phenomenon is called diurnal variation. Blood pressure is typically lowest in the morning; however, this varies widely from client to client. Additionally, the clinician might not necessarily seek the lowest possible reading. Of more concern in clients who have hypertension are the higher readings. In any case, with proper technique, the reading will still be accurate no matter what time of day the blood pressure is measured. Elevate the head of the client’s bed to 45-60 degrees. This is a comfortable position for most clients and it allows full ventilatory movement. Discomfort can increase a client's respiratory rate. Place the Oral Thermometer in the posterior lingual pocket lateral to then midline. The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe “sideways” into the back of the area under the tongue on the left or the right will access this area. A nurse is establishing a baseline for a client’s respirations. -answer, observe the clients chest movements while appearing to assess their pulse. The nurse is most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the client is unaware that they are being assessed. When clients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

Gently pulling the pinna back and upward helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement. The client who has a BMI of 35 is correct. The client who has a BMI of 35 is overweight and has a larger-than-average upperarm circumference. Therefore, the nurse should use a large blood-pressure cuff, instead of a regular-sized cuff, to ensure an accurate blood-pressure reading. The client is reporting a "stuffy" nose is correct. The client who has nasal congestion might resort to "mouth breathing," which would alter an oral temperature measurement. A respiration assessment for a full 60 seconds should also be included. The client has been fasting for blood tests is incorrect. The lack of food has no direct bearing on checking the client’s vital signs. However, recent ingestion of foods of extreme temperatures, hot or cold, can affect the accuracy of an oral temperature measurement. Infection control An exogenous HAI is an infection acquired from pathogens found outside of the client's body, such as in contaminated food. An endogenous infection develops when circumstances cause normal flora in the client's body to become altered and multiply. Such as yeast. Iatrogenic infection results from a diagnostic or therapeutic procedure, such as a urinary tract infection that develops after catheter insertion. The nurse should wear an N95 respirator mask or a high-efficiency particulate air (HEPA) filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubeola, or tuberculosis A four-point gait provides stability for the client but requires weight bearing on both legs. He moves each leg alternately with each opposing crutch, so four points of support are on the floor at all times. three-point gait requires the client to bear all of his weight on one foot. With a three-point gait, the client bears weight on both crutches and then on the uninvolved leg, repeating the sequence. The affected leg does not touch the ground The nurse should instruct the client to move the cane and then advance his weak leg forward to the cane, followed by advancing the stronger leg past the cane. This provides for the client’s body weight to be distributed between the cane and the stronger leg. Unless the nurse has any reason to believe that the client’s body fluids will splash into her eyes, the nurse does not need to wear eye protection. Emptying a urinary drainage bag for a client who has pneumonia is incorrect. Unless the nurse has any reason to believe that the client’s body fluids will splash into her eyes, the nurse does not need to wear eye protection. Irrigating a client’s abdominal wound is correct. The nurse should wear protective eyewear when irrigating a wound because wound exudate and fluids could splash into her eyes. Transporting a cerebrospinal fluid specimen to the laboratory is incorrect. The cerebrospinal fluid is in a sealed specimen container, so there is no reason for the nurse to anticipate it splashing into her eyes. Suctioning a client’s new tracheostomy tube is correct. The nurse should wear protective eyewear when performing tracheal suctioning because the client’s secretions could splash into her eyes Contractures of the extremities is correct. Contractures of the extremities are a complication of immobility because of disuse of muscles and joints. Polyuria is incorrect. Polyuria is not a finding in clients who are immobile. Urinary output decreases as immobility is prolonged, resulting in urinary stasis and increased urinary tract infections. Diarrhea is incorrect. Constipation, not diarrhea, is a complication of immobility, as gastrointestinal motility is decreased.

Crackles in the lungs is correct. Crackles in the lungs are a complication of immobility, due to mucus that collects in the dependent airways. The client often cannot cough effectively and oxygenation status declines. Pressure ulcers is correct. Pressure ulcers are a complication of immobility, due to increased pressure on skin and bony prominences, which affects tissue metabolism. The client should lift the walker and advance it about 15 cm (6 in), then set it down. This allows her a wide base of support while she moves forward. When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg. A client who has type1 diabetes mellitus and is hyperglycemic is incorrect. The nurse should identify the client who has hyperglycemia as being at risk for long-term complications such as renal failure. However, this client has no identified risk for the development of a pressure ulcer. A client who has protein calorie malnutrition is correct. A client who has poor nutritional status is at risk for the development of pressure ulcers. A client who has right-sided heart failure and 4+ edema to the lower extremities is correct. A client who has poor skin perfusion resulting from a condition such as peripheral edema is at risk for the development of pressure ulcers. A client who has postoperative delirium is correct. A client who has a decreased level of consciousness, such as delirium, is at risk for the development of pressure ulcers. Teach the client to use the call light is correct. Clients need an easy, accessible way to summon assistance, especially those who are at risk for falls. Keep the client’s bed in the lowest position is correct. With the bed in the lowest position and the wheels locked, the client is less likely to fall when getting out of bed.

Place a fall-risk identification band on the client’s wrist is correct. Fall-risk bands, usually yellow, help staff identify clients at risk and take precautions to prevent falls. Assess the client every 4 hr is incorrect. Nurses should do hourly rounding at night for clients at risk for falls and every 2 hr during daytime hours. Ensure effective pain management is correct. Uncontrolled pain can increase anxiety, promote restlessness and confusion. Attend to the client’s needs for toileting is correct. Attending to the client’s needs for toileting can reduce the risk of a client attempting to get out of bed. It is important to establish a routine for toileting to reduce the need for restraints. Assign the client to a room near the nurses’ station is correct. Assigning a client close to the nurses’ station allows the nurse and other health care professionals more immediate observation of a client. Restraints are never used as a substitute for surveillance. Orient client frequently to the environment is correct. Orienting the client frequently to the environment is beneficial in reducing a client’s confusion. The nurse should use simple and direct statements when communicating with the client. Clients older than 70 years of age are at an increased risk of acquiring an HAI. Decreased immune system function increases the susceptibility to infection.

Document restraint checks and client status every 2 hr is correct. Documentation of restraint checks and client status should take place at least every 2 hr. Educate the client’s family about restraint use is correct. It is important for the client’s family to understand the purpose of the restraint. Obtain the provider’s prescription renewal every 72 hr is incorrect. Prescriptions for restraints are to be renewed every 24 hr when used continuously. Implement passive range-of-motion exercises is correct. Passive range-of-motion exercises promote circulation and prevent skin breakdown and contractures. Release the restraint and reposition the client every 4 hr is incorrect. Restraints should be released and repositioned at least every 2 hr or according to facility policy. The nurse should wear a mask when within 3 feet of a client who requires droplet precautions. A client who has measles requires airborne precautions as well as a negative pressure room. The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client....