Nursing Practice I Set B

The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This enables the nurse to listen after exhalation without the sound of expiration interfering. The supine position is used to visually inspect the precordium, allowing the nurse to watch the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. A left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.

Design is not a threat to internal validity of the instrument just like the other options.

A pleural friction rub, heard in the lateral portion of the lungs during both inspiration and expiration, produces a squeaking or grating sound. Other abnormal sounds may clear with coughing, but pleural friction rubs don't.

For the first few days to a week after a client receives a colostomy, slight bleeding normally occurs when the stoma is touched because the surgical site is still fresh. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

When the chest tube is removed, the client is to ask to perform Valsalva’s maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an air tight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

400,000 units × 1 ml/300,000 units = Milliliters per dose 400,000 units/300,000 units = 1.3 ml

You must convert 1/8 gr to milligrams. After converting grains to milligrams, use the formula to calculate the correct dose. Conversion: 60 mg: 1 gr:: x mg: 1/8 gr 1x = 1/8 × 60/1 X = 60/8 = 7.5 mg Formula: Desired_ × X ml = Milliliters per dose Available 7.5 mg × 1 mL/10mg = 0.75 mL

When the professional nurse is involved in the informed consent process, the nurse is only witnessing the consent process and doesn’t actually obtain the consent. Only a minor who is married or emancipated can give informed consent. Obtaining consent is the responsibility of the physician. Legally, the client must be mentally competent to give consent procedure.

Use the IV flow formula Total volume × Drop factor/Time in minutes = Drops per minute

Lying down and crying can cause the fontanels to bulge, giving the nurse an inaccurate assessment. The nurse should sit the child upright and try to keep him calm and quiet. The fontanels should look almost flush with the scalp and surface, and slight pulsation should be visible. The fontanels should feel soft and either flat or slightly indented.

Scheduling may be safely and appropriately delegated. Terminations, disciplinary action, and salary increases shouldn’t be delegated to staff, which doesn’t have the power and authority to take such actions.

You must determine that 1 L equals 1000 mL. Next, use the formula in determining infusion time in hours. Total volume to infuse____ = Infusion time Milliliters per hour being infused 1000 mL/125 mL = 8 hours

Personnel budgets include salaries, benefits, Anticipated overtime costs, and potential salary increases. Office supplies and videos are part of the day-to-day operating budget. Any expense or single item of equipment costing more that 25,000 is part of the capital budget.

In a crisis situation, the nurse-manager should take command for the benefits of the client. Planning vacation time and evaluating procedure and client resources require staff input characteristics of a democratic or participative manager.

An advance directive is a document written or completed by the client and used by a facility to provide care at a time when the client can’t make her own choices. The living will and durable power of attorney are both examples of advance directives.

The nurse reports stridor to the physician immediately. This is a pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction.

The nurse maybe lawfully disclose confidential information about a client when the welfare of the person is at stake.

You must convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 150 mcg equals 0.15 mg. Use the formula to calculate the correct dose. Desired × Tablet = Tablets per dose Available 0.15 mg × 1 tablet = 1.5 tablets 0.1 mg

If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption.

The right to refuse treatment is an ethical principle of respect for the autonomy of the individual. The client can refuse treatment if he’s competent and aware of the risks and complications associated with that refusal.

Phenomenological research deals with the meaning of experiences as those who experienced the phenomenon understand it.

An employee can leave his institution anytime only if he is being treated inhumanely or he is subjected to serious insult by the employer or his representative or a crime is committed against his person. A nurse who seeks employment in a hospital knows (and should accept that).

If a client complains of abdominal pain, the nurse should check for rebound tenderness. Because this maneuver can be painful, the nurse should perform it at the end of the abdominal assessment.

A leader doesn’t have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development.

Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress codes, salary, and scheduling planned staff absences are important to any organizations but aren’t actually determined by the NCDS.