HURST Review Elevate Q-Card - Questions, Answered and well detailed Rationales An unlicensed assistive personnel (UAP) has been assigned to take vital
... [Show More] signs on several clients. Which instruction would be most important for the RN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker with a fixed rate of 70 beats/minute. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher." 4. Correct: A temperature of 101. 5 degrees F (38.6 degrees C) or higher is reported to the primary healthcare provider. The client is likely to need cultures and antibiotic therapy. 1. Incorrect: The client with emphysema will likely have a pulse oximetry reading less than 95%. This is not the most important instruction to give the UAP. 2. Incorrect: This client is likely experiencing orthostatic hypotension, so is unstable. This task should not be assigned to the UAP. The RN should perform this task. 3. Incorrect: The nurse should worry if the heart rate drops below the set pacemaker rate. It is normal for the rate to be greater than the fixed rate, but should never drop below the fixed rate. The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg. 2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed. 2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could injury the UAPs back. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury. Which action would the nurse need to perform to increase stability while initiating a client transfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly. 3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the legs to the width of the shoulders. 1. Incorrect: Do not use your back to do heavy lifting. They are not your strongest muscles. Use your legs. 2. Incorrect: A back belt will not increase the base of support. 4. Incorrect: The nurse should not lean forward or backward. The ears, shoulders, hips and feet should be aligned. A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath. 1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. 5. Incorrect: A back massage is appropriate after a bath and does not require nursing intervention. A back massage is a way of providing relaxation for the client. The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward. 4. Correct: The left shoulder should be adducted. The position of adducting the shoulder forward promotes improved chest expansion and decreases strain on the shoulder. 1. Incorrect: The right leg is positioned forward in the left lateral position. For the right lateral position, the left leg is positioned on a pillow in front of the right leg. 2. Incorrect: Both legs should not be extended for the right lateral position. The left leg should be positioned forward with the knee flexed to decrease the internal rotation of the femur. 3. Incorrect: Inversion of the feet is described as positioning the ankles toward the midline of the body. The feet should be positioned in the neutral position to maintain proper ankle alignment. A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eyelids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate. 1., 3., 4., 5., & 6. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions prevent infection, keep eyes moist, and protect the eye from injury. 2. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct. A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber. 1., 3. & 4. Correct: If you are constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts. 2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods. 5. Incorrect: Broccoli and cabbage are common gas-producing foods that can cause abdominal distention and flatulence. A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair. 3. CORRECT: The nurse is observing the client ambulate with a walker prior to discharge, to determine whether the client is using the assistive device safely. The nurse becomes concerned upon noting the client sliding the walker during ambulating. The correct use of a walker involves the client lifting and placing the walker approximately one-foot length ahead, then stepping into the non-moving walker. It is important for the walker to remain stationary when the client takes a step forward. 1. INCORRECT: This action by the client is appropriate. Proper, gripping footwear should be worn by the client at all times when ambulating. This prevents the possibility of slipping and falling. There is no cause for concern with this action. 2. INCORRECT: Another smart move is to verify the cross bars are securely locked before ambulating. When a walker is folded for storage, the locks are unlatched. When the walker is open, the locks must click into place to verify the device is safe for ambulating. No concerns here. 4. INCORRECT: When a client sits down, the walker can be placed to either side of the chair. The most important factor is for the client to use the walker to safely maneuver into the chair rather than placing the walker aside before sitting down. Placing the walker next to the chair after being seated is appropriate. The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine 3. Correct: We want to position for comfort with the knees flexed and on the side for airway. 1. Incorrect: Avoided to prevent pooling and edema in pelvis. 2. Incorrect: Partial lying on stomach is going to be painful. 4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided. The primary healthcare provider has prescribed ear irrigation for a client with earwax accumulation. In what order would the nurse perform the procedure? Remove any debris in the outer canal. Squeeze syringe with moderate force. Aim syringe at back side of ear canal. Tilt client's head to the opposite side. Fill bulb syringe with lukewarm water. Pull ear pinna upward and backward. Drag and Drop the items from one box to the other Ear wax is a substance produced by the body to clean and protect the ear canal. Usually, the ear is able to remove wax that has dried up and become useless. However, in certain circumstances, a nurse may receive a prescription to irrigate ears for clients when the wax has become impacted. After gathering the needed equipment and explaining the process to the client, the nurse should first fill the bulb syringe with warm water. Next, positioning the client is always the nurse's responsibility. For irrigating ears, the client's head should be tilted slightly toward to opposite side, so the affected ear is easily accessible. Third, using one hand, the nurse pulls the ear pinna gently upward and back to straighten the ear canal. Fourth, aim the bulb syringe toward the back and side of the ear canal. Next, the nurse squeezes the syringe with moderate force to flush out loose debris or dried wax. Sixth, any debris visible in the outer canal can be carefully removed with tweezers. The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer. 2. Correct: This is the best action by the nurse as this is a private spiritual moment for the client. Prayer is a self-care strategy that provides [Show Less]