List three (3) actions to take during the analysis or data collection step.

-You must be able to compare collected information with expected ranges and findings
-You must be able to use therapeutic communication
-The nurse must always explain the procedure being done and ask if the patient is willing

A nurse is caring for a client receiving oxygen therapy. What is the expected reference
range when obtaining oxygen saturation level? Identify four (4) reasons the reference
range may be lower.
-The expected reference range when obtaining oxygen saturation level is between 95-100%
-Client may have COPD
-Oxygen tubing may be kinked-blocking flow of oxygen
-Patient may have thick secretions blocking the inflow of oxygen
-Client is not receiving an adequate amount of oxygen for their needs

Describe tertiary prevention measures and provide one (1) example.

-Tertiary prevention is the level of prevention in which patients are learning to deal with their
condition or rehabilitating.
-Learning how to use a glucometer and administer insulin for a recent diagnosis of Diabetes
Mellitus.

List five (5) expected assessment findings for the older adult due to the physical
changes during aging.
-Increased dehydration as evidenced by decreased skin turgor and dry skin.
-Loss of bladder control as evidence by urinary incontinence
-Decreased muscle mass
-Changes in sight/visual acuity
-Hearing loss in one or both ears

When communicating with clients of various cultures the nurse must be cognizant of
communication differences. Describe how American, Middle Eastern, Asian, and Native
American differ in preference to eye contact when communicating.
-Americans: Eye contact is considered polite when speaking and listening to others
-Middle Eastern: during conversation, direct eye contact can be considered rude
-Asian: can be a strong threat, considered rude to use direct eye contact. Respectful to look
down with authority figures
-Native American-using side vision and avoiding direct eye contact is acceptable. Direct eye
contact can be considered threatening

How should the nurse respond when the client requests information about meditation?
-The nurse should respond by offering to find information about meditation for the client to
have as well as letting them know that meditation is good for relaxation and stress relief.

The nurse is caring for a client who has been diagnosed as hypovolemic and has been
ordered fluid replacement therapy. What lab values would indicate hypovolemia due to
dehydration and why?
-Increased h&h
-Increased sodium
-Increase Blood glucose
-Increased BUN
The increase in lab values is due to the decrease in fluid for these elements to be suspended
therefore, the ratio is imbalanced showing an increase in values.

A client has been prescribed a mechanical soft diet. What are three (3) indications for
this therapeutic diet?
-Absent gag reflex
-Swallowing precautions
-Recently underwent radiation treatment

What action should a nurse implement to prevent clogging of the NG tube after
medication administration?
-The nurse should flush the NG tube before, after, and in between each individual medication.

Identify three (3) manifestations of late hypoxemia.

- Dyspnea
-Blue colored lips, fingertips, and mucous membranes
-Bradycardia

What questions should a nurse ask when obtaining a health history for a client with a
history of chest pain and dyspnea?
-When obtaining a health history for a client with a history of chest pain and dyspnea, the nurse
should ask what activities brought about the onset of these symptoms and what would relieve
these symptoms. The nurse should also ask whether any labs or screenings were taken.

A client’s lab values indicate a serum sodium level of 150 mEq/L. How could this affect
the client’s vital signs?
-This will bring about an increase of fluid shifting into the vessel and therefore increasing the
blood pressure.

A nurse is caring for a client with pneumonia that is experiencing dyspnea. How should
the nurse position this client and why?
-The nurse should position the client in high fowlers position in order to promote full lung
expansion. The nurse should instruct the client to change positions often in order to prevent
stagnant fluid in the lungs which promotes infection.

PHARM