The nurse's top three priorities for this client are to weigh them, check their blood pressure, and listen for foetal heart sounds.
During labour, when does the membrane burst?Prelabor rupture, however, occurs sporadically in healthy pregnancies when the membranes burst before labour even begins. Prelabor membrane rupture may happen before or beyond the due date (at 37 weeks or later, when pregnancy is regarded as full term) (called preterm prelabor rupture if it occurs earlier than 37 weeks).
How a woman feels during pregnancy?Morning sickness typically starts one to two months after becoming pregnant and can happen at any time of the day or night. But some women experience nausea earlier, while others never do.
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which measures would the nurse take to prevent skin breakdown for a confused client? hesi eaq
At least every two hours, check the client's buttocks; clean the client right away if incontinence is found.
Which course of action will the nurse follow for a client who is on bed rest to stop skin breakdown?Every two hours, a patient should switch positions in bed to keep the blood moving. This keeps the skin healthy and shields against bedsores.
Which nursing intervention would be most effective in protecting the client from harm?To help the client feel less confused, ask a loved one or other important person who looks out for them to stay with them. It is the most crucial intervention to keep the client from getting hurt.
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which of the following actions can a staff nurse take to advance ebp at the point of care?a.establish the culture for ebp in institutional settingsb.identify clinical questions related to current nursing practicec.promote consistent practice changes among different shiftsd.reward nurses involved in ebp and help those who lack involvement
The actions which can a staff nurse take to advance EBP at the point of care is b.identify clinical questions related to current nursing practice.
EBP could be a method accustomed review, analyze, and translate the newest scientific proof. Key samples of evidence-based practice (EBP) in nursing include: Giving gas to patients with COPD: Drawing on evidence to know a way to properly provide gas to patients with chronic preventive respiratory organ sickness (COPD).
Nursing practice could also be work expertise that's direct and/or indirect patient care in clinical apply, nursing administration, education, research, or consultation within the specialty portrayed by the written document. The position should be one that will be crammed by a RN.
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the nurse continues to closely monitor client's condition. which findings would require immediate intervention by the nurse? (select all that apply. one, some or all options may be correct.)
Nurse continues to monitor client's condition, findings that require immediate intervention by the nurse is : spO2 reading has been 90% for 2 hours, serum potassium level is 3.0 m Eq/L and serum glucose is 150.
What findings would require immediate intervention by the nurse?Nursing interventions are monitoring vital signs, airway patency, and neurologic status. Managing pain and assessing the surgical site are also some interventions by nurse.
Oxygen saturation of 88% is a critical result and requires and immediate action.
Findings that require immediate actions are: heart rate less than 40 beats per minute and greater than 130 beats per minute, change in the systolic blood pressure to less than 90 mmHg and systolic blood pressure greater than 180 mmHg.
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There are several types of disinfectant agents used in the medical office. What types of items can be disinfected with glutaraldehyde, alcohol, and chlorine?
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the nurse is preparing instructions for a client who is diagnosed with osteomalacia who is at risk for skeletal injury. which information would the nurse include in the teaching?
In some cases, patients with osteomalacia may benefit from taking vitamin D, calcium, or phosphate supplements.
What should the nurse advise patients to do in order to support bone health?Nurses should evaluate the patient's understanding of osteoporosis and educate the patient about dietary intake, exercise, and other factors like increasing calcium and vitamin D intake, identifying foods high in calcium, and limiting sodas or colas, which are typically high in phosphorus.
How does the skeletal system respond to osteomalacia?The term "osteomalacia" refers to a condition in which bones become brittle and brittle. They are therefore more brittle than usual and can bend and break more easily. Lack of vitamin D is the most frequent cause. Children that have this illness are said to have rickets.
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an hiv-positive client discovers that the client's name is published in a research report on hiv care prepared by the client's nurse. the client is hurt and files a lawsuit against the nurse. which offense has the nurse committed?
Invasion of privacy is the correct answer.
What are the legal dimensions of nursing practices?
In order to avoid legal disputes, nurses must establish trustworthy nurse-patient relationships, practise within the boundaries of their competence, identify potential liabilities to their practise, and work to prevent them. Legal accountability of nurses is growing Nurses are increasingly the targets of both civil and criminal negligence cases and are being brought to court to defend their practise.
Invasion of Privacy
Privacy invasion Patients have a right to have their information kept private. HIPAA states that patients have the following rights:
1. to view a duplicate of their medical record
2. to revise their medical history
3. to obtain a list of disclosures a healthcare organization has made that aren't related to treatment, payment, or business operations in the industry
4. to ask for a restriction on specific disclosures or uses
5. to select a method for getting health information
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a child has experienced a bee-sting while at the park. the health care provider is walking by and notices the child has swelling around the eyes, lips, and face in general. what priority assessment should the nurse make at this time?
The priority assessment the nurse should make at that time is assess and establish an open airway.
Adults often experience more severe allergic reactions to bee stings than youngsters.
Many times, the only symptoms at the sting site are pain and edema. Rarely, a life-threatening allergic reaction can produce symptoms such as trouble breathing, swollen tongue, nausea, and unconsciousness. There might be a medical emergency here.
The stinger should be removed, the area should be cleaned with soap and water, and cold compresses or ice should be applied as treatment for mild to moderate reactions. Applying creams to the affected area can help ease pain.
Epinephrine may be needed for severe reactions.
The area experiences intense pain or burning for one to two hours. For 48 hours following the sting, venom-related edema is normal and can get worse. There may be 3 days of redness. The swelling may persist for 7 days.
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the nurse is caring for a client newly diagnosed with sepsis. the client has a serum lactate concentration of 6 mmol/l and fluid resuscitation has been initiated. which value indicates that the client has received adequate fluid resuscitation?
A mean arterial pressure (MAP) of 70 mm Hg value indicates that the client has received adequate fluid resuscitation.
The global perfusion pressure needed for oxygen delivery and organ perfusion is represented by the mean arterial pressure. The MAP needs to be at least 60 mm Hg and ideally between 70 and 100 mm Hg for optimum brain perfusion.
For the most majority of people, a MAP of at least 60 mm Hg or higher is necessary to provide sufficient blood flow to crucial organs including the heart, brain, and kidneys. When the blood pressure is between 70 and 100 mm Hg, doctors consider it to be normal.
Vital organs must be perfused at a minimum MAP of 60 mmHg. If MAP drops below this level for an extended period of time, end-organ symptoms like ischemia and infarction may manifest.
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the nurse is caring for a patient who has a congenital hypothyroidism. which medication would the nurse expect the primary health care provider to prescribe?
Congenital hypothyroidism is treated with the thyroid medication levothyroxine. Congenital hypothyroidism is not treated with the thyroid medication Liotrix.
What affects a person with hypothyroidism?Starting on, hypothyroidism may still not display any observable concerns. In long, undiagnosed levothyroxine may lead to a variety of problems, including obesity, joint pain, infertility, even heart disease.
Is hypothyroidism reversible?Not all patients with moderate hypothyroidism require medication. For rare occasions, the issue might resolve itself. To track the progression of hypothyroidism, it is essential to arrange follow-up appointments. Whenever hyperthyroidism will never fade up or so after several months, treatment is necessary.
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a nurse is caring for a client following foot surgery. which nursing intervention is most important for the nurse to include in the nursing care plan?
Avoid activities that force you to stoop or lean forward at the waist. Try to stand up and lean slightly backward while coughing or sneezing to enhance the curvature in your spine. Sleep with your knees bent on your side. A cushion can also be placed between your knees.
What is the nurse's top priority when a patient is diagnosed with osteoporosis?Nurses should assess the patient's understanding of osteoporosis and give instruction on nutritional consumption (such as increasing calcium and vitamin D intake, recognising calcium-rich foods, and reducing sodas or colas, which are often high in phosphorus) and exercise.
Eating a good diet, getting regular exercise, and not smoking are some of the most significant factors of preventing osteoporosis.
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a nurse admits a woman reporting severe right upper quadrant pain after eating dinner. what client risk factors lead the nurse to suspect gallbladder disease? select all that apply.
Gallbladder disease and cholesterol stones afflict two to three times as many women as males, and those who are affected are typically older than 40, multiparous, and obese.
Why do gallstone patients generally feel discomfort after eating a rich meal?Additionally, you can experience pain in your right shoulder or back, nausea, and vomiting. Biliary colic typically occurs when a fatty meal causes the gallbladder with stones to constrict.
What causes biliary colic most frequently?Biliary colic is most frequently brought on by gallstones. The regular flow of bile into the intestine is disturbed if a gallstone plugs one or both of these channels. Biliary colic is a painful condition where the muscle cells in the bile duct contract ferociously in an effort to move the stone.
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an older adult who was in a motor vehicle collision exhibits a decreased level of consciousness and serosanguinous drainage from the left ear. which action would the nurse take?
The nurse should place a sterile pad over the external ear.
Why should the nurse do so?
Lowered level of consciousness indicates towards a potential head injury, and drainage from the ear may be cerebrospinal fluid.
A sterile pad gently placed over the external ear will absorb the drainage and also prevents infection. It can also help detect the halo sign.
If a cerebrospinal fluid leak is suspected, irrigating the ear with normal saline is contraindicated. In the external meatus of the ear, packing a cotton ball or inserting a cotton-tipped swab may be traumatic and may even injure the ear further. It will also obstruct the free flow of drainage.
Therefore, the nurse should gently place a sterile pad over the external ear.
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a parent brings her 12-year-old to the clinic and informs the nurse that the child may have anorexia nervosa (an). using the diagnostic criteria for an, what subjective data should the nurse obtain during the assessment? select all that apply.
The child have a fear of gaining weight is the subjective data the nurse should obtain during the assessment.
Anorexia is characterized by intense concern about gaining weight, inaccurate weight perceptions, and unusually low physical weight. Anorexics typically resort to extreme methods to keep their weight and looks in check, which seriously compromises their quality of life.
Anorexics typically drastically restrict their calorie intake in order to prevent gaining weight or maintain their weight reduction. They could lower their calorie intake by forcing themselves to vomit shortly after eating or by misusing laxatives, diet pills, diuretics, or enemas. To reduce weight, they could go overboard. The fear of gaining weight persists no matter how much weight is lost.
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a safe and effective vaccine is available for which of the following sexually transmitted infections?
Hepatitis B & HPV vaccinations are two viral STIs that are safe and very effective. Major strides in STI prevention have been made possible by these vaccinations.
The Human Papillomavirus (HPV) vaccine, an infection that may cause genital warts and is also connected to several malignancies, is currently the sole vaccination for an STI. No vaccine exists to protect against syphilis, gonorrhea, as well as chlamydia.
All STIs are curable and quite prevalent. Many of them can be fully treated. Even STIs that are incurable can be controlled medically, including the symptoms.
The safe, efficient, and advised method of preventing hepatitis B & HPV is vaccination. If not previously protected, HPV vaccination is advised for preteens aged 11 or 12 and for everyone up to age 26.
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a nurse administers medications to the wrong client in a hospital. the client has an anaphylactic reaction to one of the medications and expires. what legal actions against the nurse can the family pursue? select all that apply.
The family may file a lawsuit against the nurse for malpractice because of improper medication .The family may file a lawsuit accusing the hospital of malpractice. A reasonable settlement might be sought by the family outside of court.
The family has the right to file a malpractice lawsuit against the nurse and the hospital. Outside of court, the family may attempt to reach a settlement. An incident that serves as a malpractice sentinel has legal repercussions. Errors in medication safety are uncommon. Although the nurse can leave the facility, she may yet face more legal repercussions. The medication nurse had a duty of care toward the patient and was required to look after them.
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a nurse knows to advise a patient who is taking atarax, an over-the-counter (otc) antihistamine, to be aware of the serious potential side effect of:
Only Atarax is an over-the-counter antihistamine that could cause seizures and other serious side effects.
What brings about a seizure?A seizure can result from anything that disrupts the regular connections made by brain nerve cells.This covers conditions including a high fever, low blood sugar, alcohol or drug withdrawal, or a concussion.However, epilepsy is labeled when a person experiences two or more seizures without any apparent explanation.
what it's like to experience a seizure?an overall sense of strangenessa physical component, such as an arm or hand, becoming stiff or twitching.Tingling in your arms and legs and a sense of déjà vu are common symptoms.
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a nurse has instituted a turn schedule for a patient to prevent skin breakdown. upon evaluation, the nurse finds that the patient has a stage ii pressure ulcer on the buttocks. which action will the nurse take next?
The action that the nurse should take after finding out that the patient has a stage II pressure ulcer on their buttocks is to reassess the patient and situation before deciding on any change.
Pressure ulcer is a type of injury that breaks down the skin and the underlying tissue. It's caused by prolonged pressure on the skin.
There are four stages of pressure ulcer:
Stage 1: Area looks red and feels warm if touched.Stage 2: Area may have an open sore, blister, or scrape.Stage 3: Area has a crater-like appearance.Stage 4: Area is really damaged and contains a large wound.To treat a stage 2 pressure ulcer, one must clean the area by rinsing to remove any loose dead tissue. One can use saline (salt water) or any specific cleaner that doesn't damage the skin.
The question above seems incomplete. The completed version is as follows:
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
a. Reassess the patient and situation.
b. Revise the turning schedule to increase the frequency.
c. Delegate turning to the nursing assistive personnel.
d. Apply medication to the area of skin that is broken down.
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using your best interpersonal skills, how would you respond to a patient who says she does not want her blood drawn because all phlebotomists hurt her?
When a patient does not want her blood to be drawn because all phlebotomists hurt her then : ask the reason why and try to resolve the issue and document it.
What should be done if patient does not agree to blood draw?If someone does not let you collect a blood specimen then explain to them that their blood test results are important to their care.
Establishing trust is very essential to prevent a patient's discomfort, so try not to rush through blood draws. Give the person time to inform you of any fears that they might have and assure them that you won't insert the needle until they've given consent.
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which health care professional would the nurse refer the client who survived a large-scale disaster event, reports a feeling of numbness for 1 month, and has notes a high score of all subscales of the impact of event scale-revised (ies-r) for further evaluation?
A mental health professional, such as a psychiatrist, psychologist, or social worker, would be the best health care professional to refer the client for further evaluation.
Who is a mental health professional?
A mental health professional is a person who provides services for the purpose of improving an individual's mental health or to treat mental illness. This may include psychiatrists, psychologists, social workers, counselors, therapists, marriage and family counselors, and other mental health professionals.
What do you mean by a Psychiatrist?
A psychiatrist is a medical specialist who specializes in the diagnosis and treatment of mental illnesses. They have a medical degree and specialized training in mental health, and are qualified to assess both the mental and physical aspects of a patient's condition. They can provide individual, family, and group therapy and prescribe medications to help treat mental health conditions.
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which assessment should the nurse complete immediately after hearing the client choked while eating? the caregiver's knowledge about feeding a person who is dysphagic. auscultate the client's lungs for adventitious breath sounds. assess the client's loc with the mini-mental status exam. determine the client's ability to swallow liquids.
Auscultate Bertha's lungs for adventitious breath sounds. Bertha's lungs should be assessed immediately for adventitious breath sounds since she is at risk for aspiration pneumonia secondary to the choking incident
What is adventitious breath sounds ?In contrast to the anticipated breath sounds mentioned above, adventitious sounds are those that are heard. Crackles, rhonchi, and wheezes are among the most frequent unforeseen sounds. Here, we'll also talk about strudor and rubs.
The partial obstruction of the larynx or trachea is typically the cause of this sound. In diseases like croup and obstruction from a foreign body, strife may be audible. Since the upper airway is partially blocked, the noise is usually loudest over the anterior neck.
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the nurse awakens a client while the client is experiencing rapid eye movement sleep. what statement made by the client indicates they were awakened during rem sleep?
I had a fantastic dream, and I still remember it all. Nearly all people who awaken while in the REM stage claim to have been dreaming. Underneath the eyelids, there is quick eye movement.
What else does REM do while you sleep?
Your brain analyzes new information and motor function from the day during REM sleep, storing some to memory, keeping others, and determining which to delete.
Is it beneficial to awaken in REM sleep?
Numerous studies have demonstrated that daytime grogginess and bad mood are caused by insufficient of slow wave sleep. Additionally, waking up in the middle of a REM cycle prevents us from accumulating memories. Try to organize your slumber in multiples of 90 minutes to ensure that you awaken during light sleep.
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the dietitian is teaching a client about cholesterol reduction strategies. which comment by the client indicates that he understands the teaching?
The comment indicating that the client understood the assignment is: "I should stay away from fats made from vegetable oils and utilized to increase fast food's shelf life."
What to do when you have cholesterol?A few dietary adjustments can lower cholesterol and enhance heart health:
Cut back on saturated fats. Your total cholesterol levels are raised by saturated fats, which are primarily found in red meat and full-fat dairy products.
Get rid of trans fats
Consume omega-3 fatty acid-rich meals.
Boost soluble fiber intake
Mix in whey protein
When there is too much of the fatty molecule known as cholesterol in your blood, you have high cholesterol. It is primarily brought on by consuming fatty foods, failing to exercise regularly, being overweight, smoking, and using alcohol. Moreover, it can run in families. By consuming a healthy diet and increasing your physical activity, you can lower your cholesterol.
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cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (pvcs). which heart rhythm will the nurse anticipate in this client if pvcs are occurring?
The nurse will anticipate premature beats followed by a compensatory pause.
what are PVCs?
PVCs, Premature ventricular contractions, are extra heartbeats beginning in one of the hearts two lower pumping chambers (ventricles). They are abnormal ectopic beats. These extra abnormal beats disrupt the regular rhythm of the heart. They sometimes cause a sensation of fluttering or a skipped beat in the chest.
PVCs are a common type of arrhythmia, i.e., irregular heartbeats.
Premature ventricular contractions are also known as premature ventricular complexes or ventricular premature beats or ventricular extrasystoles.
Therefore, the nurse will anticipate premature beats followed by a compensatory pause.
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a nurse is educating a client diagnosed with osteomalacia. which statement by the nurse is appropriate?
Answer:
"You may need to be evaluated for an underlying cause, such as renal failure."
Explanation:
as the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is
True labour contractions are generally regular, start in the back, and radiate to the belly. They frequently do not lessen with rest. False labour contractions frequently diminish with rest.
What happens during genuine labour?As labour advances, true labour contractions get stronger, more difficult to talk through, last longer, and are closer together. These will cause changes in the cervix, causing it to thin and open while facilitating the baby's descent into the pelvis.
A kind of false labour contraction is prodromal labour. It occurs during the third trimester of pregnancy and can feel quite similar to labour. Prodromal labour contractions, unlike true labour contractions, never become stronger or closer together and do not result in cervical dilatation.
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when people have conditions, such as traumatic brain injury or dementia, what is a good method to improve memory for a current activity?
Damage to your medulla oblongata might cause respiratory failure, paralysis, or loss of sensation. It's crucial to lead a cognitively stimulating existence. Mental exercise helps maintain the mind and memory in shape, just to how muscles get stronger with use.
How do cognitive neuroscience and cognitive psychology vary from one another?Cognitive neuroscience seeks to establish links between thinking and particular patterns of brain activity, whereas cognitive psychology focuses on thought processes.
An illness or injury that causes an aberrant disruption in the brain's tissue?A blow, bump, or jolt to the head, the head abruptly slamming against something, or when something pierces the skull can all result in traumatic brain injury, which is a disruption in the brain's normal function.
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an older client with chronic kidney disease has an arteriovenous fistula in the left forearm for hemodialysis. after palpating the av fistula, which finding is an indication that the av fistula is functioning properly
An arteriovenous fistula (AV) in the left forearm is used to administer hemodialysis to an elderly patient with chronic kidney disease (CKD). When the AV fistula is being palpated, enlarged veins are a sign that it is working well.
In an AV fistula, the mixing of arterial and venous blood promotes the veins to expand (A), making cancellation for hemodialysis easier. Patients are connected to a dialysis machine via an AV fistula. Your dialysis procedure begins with the insertion of two needles by a nurse into the AV fistula. Blood is drawn using a single needle and sent to a machine where it is filtered. The blood can be safely injected back into the body using the second needle.
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eating at fast-food restaurants is associated with decreased intake of calories, decreased intake of sodium, decreased intake of saturated fat, and decreased portion sizes.
"Eating at fast-food restaurants is associated with decreased intake of calories, decreased intake of sodium, decreased intake of saturated fat, and decreased portion sizes" is a statement that can be considered false.
Fast food is a type of mass-produced food for commercial resale purposes. They are usually less expensive and less nutritious compared to home-prepared meals. The food itself usually comes frozen, preheated, or precooked, so the seller can prioritize the speed of service for their customers.
Eating at fast food restaurants, or eating out in general, is associated with a significant increase in the intake of calories, sugar, sodium, and saturated fat. As for the portion size, fast food tends to come in larger portions as well. Therefore, the statement in the question above is considered false.
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an older adult client recently had a cerebrovascular accident and has residual right-sided paralysis. the client is unable to turn in bed without assistance. which action will the nurse take to help prevent skin breakdown?
Check the extremities for muscular loss and unilateral edema. Hemiplegia is a disorder that results in paralysis on one side of the body and is brought on by brain or spinal cord damage.
It results in muscular stiffness, control issues, and weakness. Symptoms of hemiplegia range in severity paralysis depending on where and how much damage was done. Damage to the left hemisphere results in weakness on the right side of the body, and vice versa, since paralysis each side of the brain hemiplegia regulates movement on the opposite side of the body.
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a client receiving chemotherapy has pruritus. in educating the client about the care plan, the nurse should caution the client against which measure?
Chemotherapeutic has been administered to a patient who has been diagnosed with lung cancer. The patient complains about nausea and a loss of appetite, which causes them to eat less.
What stage of cancer is chemotherapy?With stage four malignancies, systemic pharmacological therapies including chemotherapy or targeted therapy are frequently utilized. A clinical trial that offers novel therapies to aid in the treatment of stage 4 cancer is frequently a possibility. The 5 more prevalent malignancies' current treatment options are listed below.
What chemotherapy does to the body?The genes located inside a cell's nucleus are harmed by chemotherapy. Some medications cause harm to cells right before they divide. Some cause harm to the cells as it duplicate all of their DNA before dividing. At-risk cells are far less likely to be harmed by chemotherapy .
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