The client having a nasogastric tube inserted is disoriented. the nurse should:

Inhaltsverzeichnis Show

When a patient is receiving an enema the nozzle is inserted how far?
Which is the best position for the LPN to assist the client into for administration of an enema?
Which position would the nurse place a patient in for a cleansing enema?
What is the primary reason for placing in a left Sims position for an enema administration?

QuestionAnswer The 76 year-old client tells the Psychiatric Technician that he is constipated. Which of the following actions would be most appropriate for the Psychiatric Technician to do first? Ask the client when he last moved his bowels The 81 year-old client is complaining of difficulty moving her bowels. Which of the following medications taken by the client is the one most likely to be causing this problem? Artane It has been determined that the client is impacted with feces. Which of the following actions would be the most appropriate for the Psychiatric Technician to take first? Administer an enema as prescribed by the physician. The 92 year-old client’s BP at 10:00 am was 138/88. At 3:00 pm it is found to be 110/76. Which of the following actions by the Psychiatric Technician would be most appropriate for this client? Recheck the blood pressure and report the findings to the charge nurse. The Psychiatric Technician observes a human bite on the arm of a client who has just been in a fight. Which of the following is the most appropriate action for the Psychiatric Technician to take first? Wash the wound with soap and water and apply a bandage. What should the Psychiatric Technician do for a 12 year old client who developed a nose bleed after walking into a pole.? No other injuries are present and no alteration of consciousness is evident. Have the client sit in a chair and pinch the nose shut. The Psychiatric Technician is giving first aid to a client with a laceration in the right forearm. After applying pressure directly over the wound and elevating the affected arm the bleeding continues. Which of the following would be the most appropriate? Apply pressure at a pressure point in the upper arm of the affected arm. In a postoperative patient, forcing liquids helps prevent________? constipation. Forced feeding through a gastric tube is called? Gavage A patient with acute renal failure should receive... a high calorie diet that is low in protein and may be low in potassium and sodium. In an adult, a hemoglobin level below 11mg/dl suggests that the patient has_____________ and needs further evaluation. iron deficiency anemia The consumer who is taking a liquid iron preparation should be taught... to take the iron through a straw to avoid staining teeth. Anuria refers to a daily urine output of lesss than ______ ml. 100 During colostomy irrigation, the irrigation bag should be hung______ above the stoma. 18 inches Pernicious anemia results from failure to absorb___________in the GI tract and causes primarily GI and neurologic signs and symptoms. vitamin B12 A patient in a bladder retraining program should be given the opportunity to void_________during the day and twice at night. every 2 hours A consumer has been instructed to obtain a stool sample for ova and parasite test. Instructions should include: take the specimen to the lab without delay or refrigerate. An acetaminophen (Tylenol) overdose can serverly damage the: liver. An 83 year old complains to you about chronic constipation. Which dietary recommendation would you make? Increase foods high in fiber. Which technique is correct when suctioning a client? Enter the trachea without suction applied. Who should check insulin dosages prior to administration to the client? The Psychiatric Technician administering the dosage and another licensed person. A client is not diabetic, alert, performs her ADL's and does have long toenails. Which of the following interventions would be most appropriate for the Psychiatric Technician to take? You are doing perineal care for an adult developmentally disabled female with contractures. You would clean the perineal area in the following way: from front to back, urethra to anus You have an order to give your patient regular and NPH insulin at the same time. Which procedure below is correct? Withdraw the regular insulin first. Your client has a 3-way catheter inserted as a gastrostomy tube. One port is for the balloon, the second is for flow of the feeding. What is the third port used for? Release of gas. To ensure the success of a treatment for scabies the Psychiatric Technician know they should follow it with: Leave the solution on for 48 hours. One of the clients has dandruff and the Psychiatric Technician uses the following icated shampoo: Selsun One of the most important signs of increased intracranial pressure is: increased somnolence The best position to place a consumer in for bedrest would be:? • resting with the head of his bed elevated at 30 degrees. The client is conscious but lethargic. The Psychiatric Technician checks the client's ability to move all four extremities in an attempt to assess the: ability to respond and follow commands. A patient who is suspected of a head injury is kept N.P.O. in order to prevent: vomiting which would increase his intracranial pressure. Which explanation to the consumer best explains the cause of pneumonia? an infection of the lungs. Which diagnostic test(s) would be the most appropriate workup for tuberculosis? • patient history, physical examination, chest x-ray, and sputum culture. A patient diagnosed with pneumonia will be treated with specific antibiotics as determined by: sensitivity of the causitive organism to the antibiotic. When assessing for the signs and symptoms of pneumonia, the Psychiatric Technician is alert for : • an increased T.P.R., cough, dyspnea, mild chest pain A patient with pneumonia experiences pain when coughing. The Psychiatric Technician can help increase comfort by: splinting the patient's chest with a pillow while encouraging coughing and deep breathing on a regular basis The Psychiatric Technician caring for a patient that will need a closed reduction knows that this is: an external manipulation to realign fractured bone ends. The Psychiatric Technician noticed that the cast edges were rough and causing some skin irritationt. To make the client more comfortable, and to protect her skin, the Psychiatric Technician would: cover the rough edges of the cast with gauze dressing and notify the physician. A patient has had a cast applied for a fracture of the right femur. To make the patient more comfortable while watching TV, the Psychiatric Technician would: keep the extremity elevated to prevent edema. Because of immobility and pain medication, patient's with a full leg cast may experience: constipation After 5 days in the cast, the Psychiatric Technician noticed swelling of the patient's right toes. The Psychiatric Technician suspected circulatory impairment. The most important diagnosistic finding to look for would be: numbness and tingling in the right toes. A patient is taken to the emergency room after experiencing pain to a leg cast which was applied approximately 24 hours previous. The physician decided to bivalve the cast. A bivalved cast is one that: • is split along both sides to allow for swelling. After 3 months, the patient's cast is to be removed. Cast cutters are noisy and often frightening. To avoid increased anxiety the patient should be told that: the cast cutter will be noisy but will not cut her skin. The Psychiatric Technician knows that hepatitis B is primarily transmitted by: needle sticks. Special isolation precautions should be taken with personal items belonging to a patient with hepatitis. The Psychiatric Technician would be most careful with the person's: toothbrush Which of the following statements about diabetes is true? diabetes is characterized by an abnormality of carbohydrate metabolism. Which of the following are symptoms of diabetes? polyuria and polydipsia The Psychiatric Technician knows that the sign of hypoglycemic reaction include: Assessment signs of hyperglycemia include: Moist Skin Which of the following measures should be taken for a patient experiencing a hypoglycemic reaction: give orange juice with sugar added. Hepatitis is a disease of the: liver The client is drinking hot tea when the Psychiatric Technician goes to the bedside to take the vital signs. The best action is to: ask the client to not eat, drink or smoke for 30 minutes and then take the vital signs. The Psychiatric Technician inserted a rectal thermometer in an unconscious client and left the client unattended. The client moved, breaking the thermometer resulting in injury. The Psychiatric Technician can be held responsible for: negligence When teaching the client wound care prior to discharge, the Psychiatric Technician first instructs the client on good hand washing techniques. The rationale for this action is to: remove as many microorganisms from the skin as possible. The Psychiatric Technician provides measures to keep the client’s skin unbroken and in good condition primarily because: • intact skin is the first line of defense against infection. Professional accountability requires that the Psychiatric Technician: assume ethical responsibility for the client. The client’s family asks why their family member has been restrained. The Psychiatric Technician replies that the restraints are used primarily to: • insure the safety of the client. When inserting a nasogastric tube, the Psychiatric Technician will: give the client sips of water to facilitate insertion. When establishing goals for nursing care of clients with actual or potential sensory alterations, the Psychiatric Technician will include measures which: focus on function of compromised senses. The target distance that the Psychiatric Technician will use for insertion of a nasogastric tube is from the: tip of nose to the ear to just below the xiphoid process. The Psychiatric Technician will position the client who is orthopneic in which of the following positions? Fowler’s Which of the following statements is most appropriate for the Psychiatric Technician to make in order to determine how well the client is adapting to the process of transferring from the bed to a chair? Do you feel light-headed or dizzy?” While lying in the dorsal recumbent position, the client’s leg externally rotates. In order to prevent this, the Psychiatric Technician will utilize which of the following devices? A trochanter roll The client with an indwelling urinary catheter is to be transferred to a wheelchair. In order to prevent reflux of urine into the bladder, the Psychiatric Technician should plan to: hang the drainage bag on the chair at a site below the client’s hips. The Heimlich maneuver is successful because the action: forces air out of the lungs. Which of the following physical signs will require more assessment by the Psychiatric Technician? respiratory rate of 30. The client is on a turning and positioning schedule. When the client is turned, the Psychiatric Technician notes a small red area on the coccyx. The initial nursing intervention is to: order an air mattress for the bed. The Psychiatric Technician is legally required to: • notify authorities about instances of child abuse. When providing care to clients with varied cultural backgrounds, it is imperative that the Psychiatric Technician understand that: • current health standards should allow cultural practices in the clinical setting if safe The Psychiatric Technician is following up on the instructions given to a client using crutches. Which of the following instructions should the client be told? The client should report and numbness or tingling in the upper torso. To allow him as much independence as possible, which of the following actions should be taken by the client who uses an ambulation aid (such as a cane or crutch)? Practice how to use the ambulation aid on various terrains. When preparing the client to ambulate, which of the following should the Psychiatric Technician do? Have the client wear shoes with a nonskid sole. The Psychiatric Technician needs to log roll the client. What is the minimum number of health care workers needed to accomplish this task? Two The Psychiatric Technician needs to move the client up in bed. Which of the following is the first action the Psychiatric Technician should take? Lower the head of the bed to the lowest position. The elderly client is going to self-administer a variety of medications at home. Which of the following is the greatest factor in determining if this client will be compliant with the drug administration regimen? The client’s vision is impaired. The 47 year-old hospitalized client is alert and oriented and reasonably active. Which of the following activities is it reasonable to have this client participate in? Intake and output measurement. The client needs to incorporate ROM (range of motion) exercises into ADL. The exercise prescribed is rotation of the head. Which of the following exercises should the client be taught to do? Shaking head no. The client is recovering from am mastectomy. Which of the following ADL is a good exercise for flexion of the shoulder? Brushing and combing the hair. The client is going to self-administer 3 different medications at home. Which of the following factors will most impede his ability to be fully compliant? The client cannot always recall the side effects of some of the medications. The Psychiatric Technician is instructing the client about the dosage, purpose, and side effects about medications he will be taking at home. Which of the following actions taken by the Psychiatric Technician will be beneficial to the client? Provide frequent, short teaching sessions. The client who is visually impaired will benefit most from which of the following when administering his own medication? Use aids such as pillboxes with color-coded compartments. The client is recovering from hip replacement surgery finds it difficult to use the toilet at his home. Which of the following would be the most reasonable approach for this client? Have a raised toilet seat installed in the client’s bathroom. The client newly diagnosed with diabetes is learning to administer insulin injections to himself. Which of the following would be important for the Psychiatric Technician to know as he teaches the client about this task? The client is able to manipulate a syringe. The client recovering from an accident is paralyzed on the left side. He is otherwise active and has good flexibility. Which of the following would best allow this client to meet his need to dress himself? Velcro closures. The Psychiatric Technician is interviewing the newly admitted client with a history of cardiac problems. Which of the following questions would be most appropriate to ask of this client? “ Are you able to sleep flat on your back?” Which of the following exercise would most appropriate for the Psychiatric Technician to assist the inactive client with limited mobility? • Moving the client’s limbs through tolerated degrees of movement. The elderly client has been on bed rest for 2 days and now has a doctor’s order to begin ambulation. Which of the following should be the first action to be taken by the Psychiatric Technician who is assisting this client? Raise the head of the bed so the client is sitting up. The Psychiatric Technician has been asked to arrange ambulatory services for the discharge of an elderly client needing follow up with management of his diabetes. Which of the following is considered to be ambulatory services? Geriatric outpatient clinic. The post-op client is getting out of bed for the first time after surgery. Which of the following actions taken by the Psychiatric Technician will best facilitate this client’s ability to complete this activity? Give prescribed Demerol so it peaks when the client is getting out of bed. The client is recovering from a stroke that has left her with weakness of the right hand. Which of the following actions by the Psychiatric Technician would best allow this client to tend to her personal hygiene? • Provide her with a washcloth or sponge mitt. The Psychiatric Technician is teaching the client with a full leg cast to bathe himself. This is considered which of the following? Activities of daily living. Activities of daily living. The client is recovering from a motor vehicle accident and needs to be evaluated for his ability to bathe and dress himself. Which of the following would be an appropriate referral to assess this aspect? Occupational therapist. The client is in the terminal phase of her illness. Her ADL should be performed how? By the client as long as she is able. The 76 year-old female client is receiving instruction in bladder training to minimize her periods of incontinence. Which of the following should be included in that plan? • • A regular schedule of voiding is established. What is the best way to secure a wheelchair restraint? A quick release knot on the back of the chair. When a restraint is ordered, the patient will need to be observed at least: Every 15 minutes. When completing Active ROM exercises on a patient's elbow, which of the following is the correct motion? Flexion Which of the following reflects a basic principle of body mechanics? Pushing or pulling is easier than lifting. Which position is used for most of the physical examamination and can be uncomfortable for a patient with back problems? Supine The consumer receiving an enema should be placed in the ________position? Left Lateral Which action is inappropriate when positioning a patient? When moving a patient to the side of the bed, bed at the back and pull with your arms. The purpose of a "Clinitest" exam is to: Assess sugar in the urine. Ketones in the urine may be a reflection of: Diabetes that may be out of control. When instructing a patient to prepare for a guaiac stool specimen, it is most important to tell the client to: do not take aspirin 3 days before the test. To obtain a clean catch urine specimen from a male client, instructions should be given to: cleanse the penis using a circular motion outward from the urethral meatus. A client had 240 ml cup of ice chips; 120 ml of coffee; and a 4 ounce cup of juice. The client voided 250 ml at noon and had 120 ml of emesis. Calculate I/O. Intake: 480 ml, output: 370 ml Which fo the following urine specific gravity measurements indicates the most dilute urine? 1.010 When is the best time to collect a sputum specimen? In the morning soon after the client awakens. A patient is complaining of nausea. In which position should the nurse place the patient? Right side A patient with a urinary catheter is complaining of lower abdominal cramping. The Psychiatric Technician's first action should be: check the tubing for kinks and placement. What equipment would be in a patient's room who was diagnosed with renal calculi? urine strainer Which type of enema should be retained? Medicated A patient begins to tell the Psychiatric Technician about the death of her husband.Which would be the best therapuetic communication technique? Silence Which of the following actions would be appropriate when caring for an unconscious client? Describe the care procedures as you provide the care to the client. Advance directives: are required by law to be discussed on admission to health care facilities. Discharge teaching should be individualized and... must be documented. Discharge planning begins... on admission to the unit. When giving a tepid sponge bath, cloths are placed on the client's... axillae and groin. When applying a roller bandage (ace wrap) to an upper extremity, which technique should the Psychiatric Technician use? wrap from the fingers to the shoulder. Which of the following measures will the Psychiatric Technician carry out to help the client on bed rest avoid pressure sores in the most common location? Turn the client from side to side relieving pressure on the sacrum. The Psychiatric Technician is caring for an African-American woman on complete bed rest. In assessing the skin integrity of this client which of the following would be the first indication that a pressure sore may be developing on the client’s heel? The heel feels warm to the touch. The Psychiatric Technician weighs the client daily for which of the following reasons? To check for the presence of fluid retention. The client in chronic renal failure has received too much fluid and now has water intoxication. Which of the following would the Psychiatric Technician expect to see in this client? Confusion. The client in complete renal failure has received too much fluid. Which of the following would be the most effective intervention to restore the normal level of hydration for his client? Restrict fluid intake as ordered. Which of the following interventions by the Psychiatric Technician will best address the nutritional needs of the elderly client? Assess and evaluate the client’s dietary habits. The Psychiatric Technician is monitoring a group of clients in an acute care inpatient setting during mealtime. Which of the following clients will require use of the Heimlich maneuver by the Psychiatric Technician? The client who is making high pitched sounds while inhaling. The Psychiatric Technician is performing the Heimlich maneuver on a client when the client becomes unconscious. After easing he client to the floor what is the next step to be taken by the Psychiatric Technician? Perform a finger sweep of the victim’s mouth. The Psychiatric Technician is caring for a group of clients who are recovering from surgery. Which of the following client is most in need of pain management? The client with a pulse of 120, respirations of 22 and BP of 140/92. The client has returned from the ER after having a plaster cast applied to his left leg. He begins to complain of pain in the leg but has already received his pain medication. Which of the following measures should the Psychiatric Technician take next? Apply an ice pack to the affected area. A client is not diabetic, alert, performs her ADL's and does have long toenails. Which of the following interventions would be most appropriate for the Psychiatric Technician to take? Soak the feet in warm water and clip straight across with a nail clipper. Which of the following types of drainage would be considered “normal” drainage from a gastrostomy tube? Pale, yellow-green liquid. The diabetic client who is alert and manages her own ADL independently states that her toenails are long and need to be trimmed. Which of the following actions would be most appropriate for the Psychiatric Technician to take? Request that a podiatrist visit the client. The Psychiatric Technician is caring for an elderly client and is promoting the client’s personal hygiene. Which of the following would be the most appropriate action for the Psychiatric Technician to take? Place a chair in the shower in which a hand-held shower head is installed. The Psychiatric Technician is encouraging the client to participate in active range of motion involving flexion of the shoulder. Which of the following best addresses this need? Have the client comb her hair. The physician has ordered passive range of motion exercises for the client’s left elbow. Which of the following would be most appropriate? Gently move the client’s left hand toward his left shoulder and extend it. The Psychiatric Technician is preparing to move a heavy client from the bed to a chair by using a mechanical lift. Which of the following is the correct placement of chains used to connect the sling and the lift? Attach the longer chains to the section that supports the upper body. Which of the following interventions by the Psychiatric Technician would be most helpful in promoting the comfort of the client with a Gastrostomy tube? Have the client rinse his mouth with alcohol-free mouth wash q 2h. After tripping in the hall, the client states that her tooth has fallen out. Which of the following actions by the Psychiatric Technician would be most appropriate? Place the tooth in a cup of milk. The client is found to be incontinent of urine. Which of the following responses by the Psychiatric Technician would be most appropriate? “Your briefs need to be changed. Would you like some help?” Which of the following behavior changes of the client is most likely to be seen in a client with a toothache? Client is selecting foods moderate in temperature. The Psychiatric Technician has been assigned the task of checking the Hoyer lift. Which of the following would be most critical for the Psychiatric Technician to do? Check that the casters move freely. The 72 year-old client has an unsteady gait and is on slip/fall precautions. Which of the following interventions by the Psychiatric Technician are most urgent? Wipe up a spill on the floor. 29. The 56 year-old client is returning from the OR and needs to be moved from the gurney to the client’s bed. Which of the following is the first step to be taken prior to moving the client? Assess the client’s ability to cooperate. The client receiving chemotherapy refuses to eat and says, “Just let me sleep.” What would be the best response by the Psychiatric Technician? Say, “You seem discouraged.” When making a bed at which height should the bed be? At waist level. When changing the linen on a bed, the main reason why the linen is rolled is which of the following? Reduce the transmission of organisms. The client taking an MAOI is to undergo surgery for repair of a hernia. Which of the following should he be instructed to do as per doctor’s order? Stop taking this medication 2 weeks before surgery. The Psychiatric Technician is assessing the client’s fluid status. Which of the following is the best indication of this in the adult client? Skin turgor. The Psychiatric Technician is caring for a client who is recovering from a fractured fibula but who has no other physical problems. Which of the following diets would be the most appropriate one for this client? Well balanced diet Which of the following diets would be most appropriate for a client recovering from severe burns? High calorie, high protein diet Dietary management of the hypertensive client is accomplished through which of the following interventions? 2 Gm Na diet. Which of the following best describes the function of the Sinoatrial (SA) node? To act as the primary pacemaker of the heart. Which of the following best describes a client’s pre-morbid personality? The client was friendly and outgoing before her surgery. The Psychiatric Technician enters a client’s room and finds the client unconscious and calls for help. According to the American Heart Association what is the next action the Psychiatric Technician should take? Open the airway The client is unresponsive, has a pulse, but is not breathing. According to the American Heart Association which of the following actions should the Psychiatric Technician take? Open the airway and give the client a breath once every 5 seconds. The client with a history of right sided heart failure should be monitored for which of the following symptoms? Peripheral edema. Which of the following best describes the “Babinski” sign? Movement of the great toe upward and fanning of the other toes. The lab results indicate that the client has a fasting blood glucose level of 100 mg/dl. What action by the Psychiatric Technician would be most appropriate? Notify the physician and take no other action. The client receiving Lasix has a serum potassium level of 4.9 mEq/L. What action by the Psychiatric Technician would be most appropriate for this client? Notify the physician, if requested; take no other action. The client’s hematocrit is 39% following a hysterectomy. There is no unusual post op bleeding. Which action by the Psychiatric Technician would be most appropriate for this client? Notify the physician; take no other action. The Psych Tech is preparing to make a bed occupied by the client. Which of the following is the first action to be taken by the Psych Tech? Place the bed at waist level. The Psych Tech is preparing a client for elective surgery that will take place in 2 weeks. The client is taking a variety of medications including an MAOI. After checking with the physician, which of the following instructions would the Psych Tech offer? Stop taking the MAOI 2 weeks prior to the surgery. The client is receiving tube feedings while recovering from ingestion of lye. Following the feeding the client complains of abdominal cramping. Which of the following is the most likely cause of this? The feeding was administered too quickly. The Psychiatric Technician is assisting the client with inflammatory bowel disease to complete his hospital menu. Which of the following would be appropriate items to be included in this client’s diet? Broiled fish The client with full upper and lower dentures is experiencing a grand mal seizure. Which of the following actions is the most appropriate for the Psychiatric Technician to take at this time? Do nothing, as the seizure must run it’s course. The client you are caring for has recently discovered he is allergic to tomatoes. Which of the following actions by the Psychiatric Technician would be most appropriate? Instruct client that a “sense of doom” may precede an anaphylactic reaction. The C.B.C. report is back from the laboratory, the Psychiatric Technician knows that a C.B.C. is a: complete blood count The Psychiatric Technician knows that a hematocrit level: measures the red blood cells in a given amount of blood The Psychiatric Technician knows that the physician would order which of the following diets for a patient with a possible upper GI bleed: frequent, small feedings The Psychiatric Technician knows that the term "scoliosis" refers to: a lateral curvature of a part of the vertebral column The staphylococcal bacteria: is highly contagious When administering oxygen it is important for the Psychiatric Technician to: remove all sources of ignition from the area Which of the following terms refers to the bluish or grayish discoloration of the mucosa and nail beds that is a symptom of oxygen deficiency? cyanosis You have an order to obtain a urine culture and sensitivity from a Foley catheter. The procedure for obtaining a urine specimen from a Foley catheter is to: Clean the rubber port with alcohol and withdraw the specimen with a syringe. A brace is prescribed to correct a consumer's scoliosis. The Psychiatric Technician realizes that: The consumer should always wear a clean t-shirt under the brace A client falls and can’t bear weight on his/her left leg. He/she is brought into the E.R. with a suspected fracture of the left hip. On examination the Psychiatric Technician would expect the leg to be. shortened, with external rotation. A client had an elevation of his W B C's. An elevated "W. B. C." might indicate that the client: has an infection A client is experiencing abnormal breathing which involves very deep to very shallow respirations with temporary apnea. This type of irregular breathing pattern is referred to as: Cheyne-Stroke's. A client is having her blood pressure taken by the Psychiatric Technician. The client asks what does blood pressure represent. The best response the Psychiatric Technician would give is: It is a measure of the pressure exerted by the blood as it pulsates through the arteries. A client that has crutches needs instructions on how to get upstairs. The Psychiatric Technician tells him/her to stand at the foot of the stairs bearing weight on their good leg and crutches. Put weight on the crutch handles and lift the good leg up on the first stair. Put weight on the good leg, and lift the other leg and crutches up to that step. Repeat for each step. A clinical manifestation of further hypoxia for would be: hyperventilation A moderately retarded developmentally disabled client tells the Psychiatric Technician he has reddish bump that is not sore on his penis? The Psychiatric Technician notifies the physician as this may be indicative of? Syphilis A patient diagnosed with a Stage III decubitus needs wound care. The Psychiatric Technician cleans the wound with an antiseptic from clean to dirty. A patient who has liver disease would receive a diet restricted in: sodium and fluid A pedal pule site is used to: Determine circulation to the foot. A pulse rate of 140 beats per minute is known as: tachycardia Ascites is best described as: an accumulation of fluid in the peritoneal cavity. Communicable diseases are: diseases that can be transmitted from one person to another Coronary artery disease is a condition in which there is: a narrowing of coronary arteries sufficient to preven adequate blood supply Organisms that are normally found in the body are called: flora Patients may acquire infections while in the hospital setting. These infections are called: nosocomial The purpose of a Sitz bath is: to cleanse and soothe the perineal area. Which might be the best action to initiate for a stage 1 decubitus? Keep pressure off the area. Which statement most accurately describes a stage 2 decubitus? There is a blister on the skin. The most accurate pulse for children under 2 years of age is the: apical A patient is admitted with the following vital signs: Radial pulse 68, Respirations 14, Oral temperature 98.9, BP 164/92. Which term indicates the abnormal value? Hypertensive When you are finished measuring a patient's temperature with a glass thermometer, which action would be most appropriate? Clean and disinfect the thermometer. A temperature of 99.5 Fahrenheit is equivent to ____degrees Celsius? 37.5 In the absense of a fever, you would expect the body temperature to peak: afternoon Where is the location to check for bilateral pedal pulse? On top of each foot. Which of the following data is within the normal range for an adult? Blood pressure 114/74 A consumer has difficulty swallowing. Which intervention would be most helpful? Encourage swallowing after each portion of food. Which of the following is an example fo a high quality protein source? Eggs Which of following would be appropriate for a patient on a sodium retricted diet? Blends of herbs and spices to season foods. The goal of _________diet is to limit foods that stimulate the production of gastric acid. bland What would you instruct a consumer to avoid eating if the consumer is on a low-residue diet? whole grain bread and fruits. Your male patient is requesting assistance with voiding. The patient is unable to ambulate to the bathroom. Which technique would be most helpful? Assist the patient to a standing position with the urinal. The rationale for use of hand rolls is: Prevention of flexion contractures of the hand. What is the best way to secure a wheelchair restraint? A quick release knot on the back of the chair. When applying a sterile gown touch only the inside of the gown. Which assessment finding relates most directly to pain? Dilated pupils Which statement by the patient would warrant further investigation? "I should request pain medication when I can no longer tolerate the pain." The healthcare worker knows that the most objective positive response from a Harris flush is when: Bubbles return in the fluid when the cannister is lowered. The healthcare worker knows that the most objective positive response from a Harris flush is when: Bubbles return in the fluid when the cannister is lowered. The bedside blood glucose reading is 110 at 0700. The Psychiatric Technician knows that: Breakfast may be given. The psychiatric technician is attending an updated class on medication administration at her work site. She learns that there are now six rights regarding accurate administration of medication. The sixth one would be: Right documentation. The psychiatric technician has several clients that are receiving Tegretol (carbamazepine). He knows to closely monitor the blood laboratory values since this medication can cause: Aplastic anemia and agranulocytosis. A psychiatric technician is employed at a group home with six mentally ill clients. She is starting to work with a new client of Chinese descent. She’s in charge of meal planning and would know that dietary habits of this culture would include: There is a specific order for food to be eaten at meals. Peanuts/soybeans are common. A client recovering from alcoholism reports that his physician said he was deficient in thiamine. The client asks the psychiatric technician what foods are rich in thiamine.The psychiatric technician responds by stating: Whole-grain and enriched breads and cereals, liver, beef, peas and beans and nuts. An elderly Iranian American male client informs the psychiatric technician during the admission process that he is Muslim. The psychiatric technician would be aware that this client: May pray five times a day facing east and may want to wash before prayers. The psychiatric technician is assigned to administer medication and treatments. A female client is to receive a topical medication to her face. How would the psychiatric technician apply this medication? Start with the forehead and spread down each side of the face in one direction. The least accurate body site for taking a temperature would be: Axillary. The psychiatric technician is instructed to measure the oxygen saturation in arterial blood for a client using a pulse oximeter. He would know that the normal range for oxygen saturation would be: 100-95. The pain scale that is ideal for children would be the: FACES Pain Rating Scale (A Happy Face to a Crying Face). The psychiatric technician recognizes the value for cholesterol should be less than: 200. A client is suffering from hypotension. The physician writes an order for the client to be placed in a Trendelenburg position. The psychiatric technician would position the bed by: Lowering the head of the bed while the foot is raised in a straight incline. The psychiatric technician is reviewing recent laboratory tests for a client. She sees that the urine specific gravity test had a value of 1.025. Therefore, she knows that this is: Normal. The psychiatric technician must assesses clients experiencing dementia and taking medications like Aricept (donepezil), Reminyl (galantamine) and Namenda (memantine) for the possible side effects of: Dizziness, headache, and gastrointestinal upset. An elderly female client asks the psychiatric technician, “What is Lunesta used for and what would be the highest dosage a person can take?” The psychiatric technician responds by stating: Insomnia and 3 mg. A client has had consistent blood pressure readings of 136/80 and is concerned about the possibility of hypertension in the future and is fearful about taking medication. What dietary supplement should be increased? Calcium and potassium. Which of the following nursing interventions has the highest priority for severe withdrawal from alcohol? Maintenance of nutrition and hydration. Your client has a sprained wrist and the physician has ordered an elastic bandage application. Which of the following techniques in conjunction with the ace wrap is most appropriate? Place the extremity on a pillow and wrap the arm from distal to proximal What would be the most important consideration while assisting a disoriented and confused client with activities of daily living? Provide a simple structured enviroment and assist as required. Whch foods would a Psychiatric Technician encourage client diagnosed with osteoporosis to include in his/her diet. Liver, milk, egg yolks When assisting a client to a chair from a bed, it is the Psychiatric Technician's major responsibility to… maintain safety. When pressure is applied to a patient's toes causing them to be positioned in plantar-flexion for an extended period the primary complication that may arise is… Alteration in the length of the muscles in the feet When teaching the patient to use crutches it is most important to… Be sure they understand that their body weight is primarily supported by the hands and arms When the Psychiatric Technician is practicing good handwashing technique, she will turn off the faucet: with a paper towel Which actions would yield the most accurate oral temperature after the client has just smoked a cigarette? Wait 15 minutes to take the temperature. Which area must be suctioned first when using a single catheter? Tracheostomy. Which bed position is most likely to help a client with breathing difficulties: Fowler's position. Which blood pressure reading would be regarded as hypertension in the adult : Over 160 mm Hg systolic and/or 110 mm Hg diastolic. Which blood sugar is in the normal range for blood glucose? 90 Which blood sugar would necessitate holding the dose of insulin and notifying the physician? 30 Which blood sugar would require administration of extra insulin? 150 Which of the following conditions, in addition to trauma, contributes to disorientation in the elderly who have recently been admitted to the hospital? New surroundings and routines. Which of the following drinks would make a hypnotic less affective? Mountain Dew. Which of the following statements made by the patient indicates that the teaching you have given them about crutch walking using a swing through gait has been effective "I will have both crutches move forward first, followed by both legs, returning the weight of the body to the uninjured leg." Which procedure is necessary when removing liquid medication from a glass vial? Inject air into the vial to displace the liquid to be removed. Which solutions would the Psychiatric Technician instruct the family to purchase for tracheostomy care? Normal saline and hydrogen peroxide. Which symptoms are most characteristic of immune compromised clients: Fatigue, night sweats, intermittent fever, and severe diarrhea. When using acetone to remove tape adhesive, which precaution should the Psychiatric Technician take? Never use acetone on an open wound Which roller bandage (ace wrap) would appropriate for an average adult client's extremity 2 inch A client has roller bandage on the right hand. What area should be assessed Fingers on both hands Antiembolism stockings are ordered because... it will increase return circulation Sterile technique is indicated for which of the following nursing procedures? catheterizing The client body should be bathed in what order? Face, arms and hands, chest and abdomen, legs and feet, back and perineum The client has been diagnosed with a urinary tract infection. The patient complained of the following signs and symptoms Hematuria, frequency, and flank pain. The client with a history of left sided heart failure should be monitored for which of the following signs or symptoms? Dyspnea. The client with depression is being treated for fractured ribs. She has no other medical problems. Which of the following would be the most appropriate diet for this client? Well balanced diet Family members should understand that showing sadness or crying in front of the dying person is: Is acceptable and demonstrates how the person feels Your are assisting your client who has had a stroke. She needs help getting into the wheelchair. Which is the best way to place the wheelchair? Position the chair by the client's unaffected side with the bed locked The client has a CVA three years ago that resulted in right-sided hemiparesis. You are assisting the client with getting dressed in the morning. which technique is most appropriate? Assist the client to putting the shirt on the right arm then have the client put on the left sleeve. You are assisting your client, who has had a CVA with undressing before bedtime. Which is the best technique to use? Remove the garment from the least affected extremity first. Your client's oral temperature is 35 degrees Celsius. You will be taking the client to the park for the day. The outdoor temperature is 70 degrees Fahrenheit. Which is the most appropriate intervention for this client? Dress the client in warm clothing with a hat Your client has a sprained ankle. You had the client rest, applied ice and placed the elastic wrap as ordered. What is your next action? Elevate the on a pillow or stool. Your client has returned from the acute hospital after having abdominal surgery with an abdominal dressing that needs to remain intact for 2 more days. Which type of dressing will be most helpful to avoid skin irritation from the tape? A Scultetus bandage placed on the abdomen. Your client has had a new onset stroke. The family asks why they cannot understand what the client is saying. You explain to the family, that as a result of the stroke the client may be exhibiting: Expressive aphasia You are reading the lab work that was returned for your client. Which value, on the urinalysis, would be considered within normal parameters? Specific gravity 1.020 What information should you provide for your client who is on tetracycline for chronic acne prior to an outing? Have the client wear sunglasses and a hat. Your client has been prescribed Motrin, a common NSAID for chronic knee pain. Which routine assessment is necessary for this drug? Assess for ecchymosed areas. When you review the drug history, your client indicates he has been taking aspirin three times a day for a sore knee. Which statement by the client is of most concern? Sometimes I hear a funny ringing in my ears. The Psychiatric Technician is working in a drug rehabilitation facility. Clonidine (Catapres) has been ordered for the client. Which assessment is necessary prior to administration of the medication? Blood pressure The Psychiatric Technician is discharging a client from the facility. Targeted teaching is done on the Lopressor (Metroprolol). Teaching shall include: You will not be able to drink grapefruit juice when taking this drug. A client tells you that he is taking a drug to help lower cholesterol. As a result, you instruct the client to avoid grapefruit juice since this may cause: Renal failure The client has been constipated and a cleansing enema is ordered. The Psychiatric Technician knows that the following guideline is necessary: Use water that is 105 degrees Fahrenheit. A return flow enema is ordered for a client after abdominal surgery. Which statement reflects the correct technique for this procedure? The container is held 12 to 18 inches above the client then lowered toward the floor to help relieve flatus. A parent called the clinic to indicate that her child has been itching around the anus. The Physician indicates helminthes may be the cause. The best technique to obtain the specimen is: Apply cellophane tape to the anus to capture the eggs The client has had Haloperidol (Haldol) ordered for agitation. The client will be discharged on the medication with a caregiver. What information is necessary to convey to the caregiver? Do not withdraw the medication abruptly. Your client has a soap suds enema ordered. Which statement below is correct for the administration of a soap suds enema? 1 tsp. or 5 ml castile soap per 1000 ml of water. When bathing the client, which is the best technique for cleaning the eyes? Clean the eyes from the inner to outer canthus You are administering morning medications to your client in the group home. Which is the best fluid to have available for the client to swallow the medications? Water You have obtained a stool specimen for ova and parasites which will be sent to the lab. Which principle is most important in relation to this specimen? Keep the specimen warm Your client tripped on the curb. Subsequently, he was taken to the urgent care where a fractured radius was diagnosed. A plaster cast was applied to the extremity. What teaching is essential for the client with a cast? Do not place objects between the cast and the arm Which adaptive support would be most helpful for a client, who has had a CVA, achieve self-help skills with dressing? The use of Velcro closures You are assisting your client, who cannot transfer independently from the bed to the chair. What is the recommended placement of the chair before transfer? The chair is at the foot of the bed, at a 45 degree angle, facing the head of the bed You are assisting your client who has had a stroke. She needs help getting into the wheelchair. Which is the best way to place the wheelchair? Position the chair by the client’s unaffected side with the bed locked. The client is receiving Lodine (etodolac) and should be given which of the following instructions? Avoid the concurrent use of alcohol, aspirin and NSAIDs. The client is experiencing speech difficulties while recovering from a cerebral vascular accident. Which of the following actions should the Psychiatric Technician take to minimize frustration caused by communication problems? Listen and observe for all nonverbal cues The client is recovering from a MI. The Psychiatric Technician knows that the MI is least likely going to affect which of the following? The client's ability to make decisions The client with a positive wound culture is managed with which of the following isolation precautions? Contact precautions The client Admitted to the unit has an initial diagnosis of active T.B. Which of the following is true about the care of this client? All hospital personnel exposed to this individual must use a specially fitted facemask. The Psychiatric Technician is helping to plan the activity for a client recovering from an MI. Which of the following would be actions to be taken the client? Follow a low sodium diet The client experiencing communication difficulties while recovering from a from a cerebral vascular accident. Which of the following interventions should the Psychiatric Technician take? Restate verbalizations to see if correct meaning is understood. Which of the following helps a child cope with procedures to be done in a hospital? Allow the child to handle the equipment ahead of time, when possible. The client is having some impairment of swallowing following a stroke. Which of the following actions will help reduce the likelihood of the client aspirating his foods? Reduce distractions in the room. When assisting the client to transfer from the bed to a chair it would be important for the health care worker to do which of the following? Flex knees and keep feet about 18 inches apart when lifting. The clients skin has become dry and flaky. Which of the following interventions would be the best for the Psychiatric Technician to take? Apply moisturizing lotion to the skin The client with hemiparesis is to be discharged in the near future. The Psychiatric Technician might suggest which of the following to the client to promote safety regarding showering? Consider installing grab bars in the shower and tub area. The client is receiving anticoagulant therapy. Which of the following should the Psychiatric Technician instruct the client to do regarding oral hygiene? Brush the teeth gently do not floss The client is being taught to self-administer an enema. Which of the following should the client be told is a reason to stop administering the enema? Diaphoresis or shortness of breathe Acyclovir is being administered to the patient to treat which of these genital herpes infection The client has begun a regimen that includes the use of coumadin. Patient teaching would include telling the client to refrain from taking which of the following over the counter drugs unless directed by the physician? Acetylsalicylic acid The client is being prepared for a mastectomy. Which of the following should the Psychiatric Technician do to prepare the client psychologically? Allow the client to express her concerns and answer her questions The client receiving chemotherapy refuses to eat and says, “Just let me sleep.” What would be the best response by the Psychiatric Technician? Say, “You seem discouraged.” Oral care for a consumer with stomatitis includes: mouth rinses with hydrogen peroxide and water three times a day A patient with a gastric ulcer may complain of: gnawing and burning epigastric pain. In developing a diet for a patient with a peptic ulcer, the psychiatric Technician should remember this guideline: Include foods in the diet that the patient can tolerate If a patient has a gastric tube in place to suction, the Psychiatric Technician should expect a physician's order for: potassium chloride Clients with gastric ulcers frequently complain of pain _________. shortly after eating The Psychiatric Technician should not give analgesics to a consumer with abdominal pain caused by appendicitis because: the drugs may mask the pain that accompanies a ruptured appendix. When a rectal tube is used to relieve flatulence or enhance peristalsis, it should be inserted for no more than _____ minutes. 20 A consumer with _________ should consume a diet low in residue, fiber and high in calories, proteins, and carbohydrates and should take vitamin supplements (especially vitamin K). Crohn's disease Which of the following is contraindicated in a patient with appendicitis, acute surgical abdomen, fecal impaction, or intestinal obstruction? Mineral Oil. The consumer with cirrhosis may have portal hypertension. This condition can lead to which other complications? Esophageal varices. The first symptom of pancreatitis is: steady epigastric pain or left upper quadrant pain that radiates from the umbilical area or back. Serum levels of _______________ reveal when the liver is adequately detoxifying medications. aspartate aminotransferase and alanine aminotransferase Alcohol is metabolized primarily in the: liver. The total parental nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before because: cold fluid can cause pain and venospasm. Constipation is a common adverse reaction to aluminum hydroxide A patient undergoing dialysis should take a vitamin supplement and eat foods that are high in: calories. To catheterize a female patient, the Psychiatric Technician should place her in the _______________position dorsal recumbent In total parenteral nutrition, ______ is the most reliable indicator of a positive response to therapy. weight gain It is the most important for the Psychiatric Technician to monitor _____ in a patient receiving total parental nutrition? Glucose and electrolyte levels A consumer with an ileostomy shouldn't eat_____ because it may obstruct the pouch opening. Corn Drainage of more than_____ of fluid daily from a nasogastric tube may suggest intestinal obstruction. 3000 Which intervention in contraindicated for the patient who has ingested poison and is having seizures or in semi-conscious or comatose? inducing vomiting When assessing a client for bladder distention, The psychiatric technician should check: The contour of the lower abdomen for a rounded mass above the symphysis pubis. If a total parental nutrition infusion must be interrupted, the psychiatric technician should administer_____ at a similar rate because abrupt session can result in hypoglycemia. Dextrose 5% in water

When a patient is receiving an enema the nozzle is inserted how far?

Gently insert the tip of the nozzle into the anus, and continue inserting it 10 centimeters (3–4 inches) into the rectum. Slowly squeeze the liquid from the container until it is empty, then gently remove the nozzle from the rectum.

Which is the best position for the LPN to assist the client into for administration of an enema?

The ideal positions for enema administration are the right side position, left side position, knee chest position, and on the back.

Which position would the nurse place a patient in for a cleansing enema?

Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon.

What is the primary reason for placing in a left Sims position for an enema administration?

Rectal tube insertion procedure The left knee is comfortably flexed. This is called the Sims position. The goal is to relax the abdominal muscles and decrease pressure within the abdomen.