170 Exam II

timeline & symptoms

1-3 months 1-2 weeks days-hours (*Cheyne Stokes Respirations*)

average amount of times to urinate in a day

5-6 times/day

normal urination

50-60 mL/hr or about 1,500 mL/day

intentional torts

assault battery false imprisonment invasion of privacy

which phase is evaluation most similar to

assessment

what is primary data

directly from the patient

do NOT chart... in pt chart

incident reports

what are open-ended questions

questions that allow broad responses

lifestyle factors that can affect elimination

stress & anxiety activity diet medications

assault

threat/attempt to do harm

A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? evaluation implementation assessment nursing diagnosis

assessment

who is most at risk for a UTI

elderly & pregnant women

fidelity means

keep your word

Types of urinary incontinence

urge stress reflex functional transient overflow (leakage of distended bladder)

A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care? Chronic minimal urgent expectant

urgent

what do we do after collecting data

validate data, possibly recheck, organize data/categorize, and document

what is subjective data

what the pt "says" (symptoms)

A nurse is caring for a client who is nearing the end of life. Which of the following responses by the nurse supports the client's dignity What would you like to know about your medications I expect you will feel much better in a few days What can I do to help you fell more independent I think you should allow your family to make your health care decisions You must be getting tired of lying in bed

what would you like to know about your medication what can I do to help you feel more independent

what is objective data

what you observe/what is measurable (signs)

hospice services include who

wound care NP case managers CNAs social workers volunteers

false imprisonment

wrongful restraint

Match the component of the plan of care with the related information. Heart rate 34 beats/min impaired cardiac function, supported by bradycardia HR will return to 60 to 90 beats/min in 58 hours; monitor cardiac rhythm continuously hr 70-79 beats/min x 48 hours; goal met; discontinue goal \\\\\\ nursing diagnosis measurable goal and intervention evaluation key assessment data

Heart rate 34 beats = key assessment impaired cardiac function, supported by bradycardia = nursing diagnosis HR will return to 60 to 90 beats/min in 58 hours; monitor cardiac rhythm continuously = measurable goal and intervention HR 70-79 beats/min x 48 hours; goal met; discontinue goal

A charge nurse is delegating tasks to other staff members on the floor including an LPN. Which task should the charge nurse delegate to the LPN? Creating a plan of care for a client who is recovering following a stroke Assessing a pressure injury on a client who is on bed rest. Providing nasopharyngeal suctioning for a client who has pneumonia. Teaching a client who has asthma to use a metered-dose inhaler

Providing nasopharyngeal suctioning for a client who has pneumonia

A patient is admitted with elevated blood urea nitrogen (BUN) and creatinine levels, as well as anuria. Based on these findings, the nurse suspects which diagnosis? Urinary tract infection Renal calculi Enuresis Renal failure

Renal failure

when delegating think...

SAFETY

A nurse is caring for a 64-year-old bedridden female who is a fall risk. The nurse must help the patient urinate in a bedpan. What would be the most appropriate position to facilitate urination Prone Semi-fowler's Standing Recumbent

Semi-fowler's

steps of diagnostic reasoning

Step 1: Analyze and Interpret Data Step 2: Draw Conclusion about Health Status Step 3: Verify Conclusion with the Patient Step 4: Write the Diagnostic Statement Step 5: Prioritize the Problems

A female patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this finding in the patient's healthcare record? Transient incontinence Overflow incontinence Urge incontinence Stress incontinence

Stress incontinence

A nurse is teaching a client about hospice care. Which of the following information should the nurse include You must have a terminal illness You are eligible for hospice care if you are expected to live for 12 months You can continue treatment to cure your illness You accept palliative care for comfort The health care provider must officially state that you are terminally ill

You must have a terminal illness you accept palliative care for comfort the health care provider must officially state that you are terminally ill

A nurse has received change of shift report for a gourd of clients. which of the following clients should the nurse plan too see first? A client who is receiving blood transfusion and reports urticaria A client who has back pain and is requesting a muscle relaxant medication a client who has an ankle sprain and requests toileting assistance a client who has chronic migraines and reports a headache

a client who is receiving a blood transfusion and reports urticaria

The nurse is making assignments for the shift. Which assignment would the nurse delegate to the unlicensed assistive personnel (UAP)? Teaching the patient to perform the credé's maneuver Irrigating an indwelling catheter Applying a condom catheter Obtaining the patients urinary history and physical assessment

applying a condom catheter

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? assessment diagnosis implementation evaluation

assessment

A nurse at an urgent care clinical is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? evaluation implementation analysis assessment

assessment

3.In what order should an RN perform the steps of the nursing process? analysis planning implementation evaluation assessment

assessment analysis planning implementation evaluation

Which component does the nurse analyze to identify patient problems and select appropriate nursing diagnoses? plan of care assessment data nursing outcomes nursing taxonomy

assessment data

A nurse is caring for a client who has a terminal illness and reports feeling isolated from family and friends. Which of the following actions should the nurse take? Limit visitors to one to two people Assist in scheduling friends and family to visit Discourage face to face visits for the client Instruct the client to limit their use of online support groups

assist in scheduling friends and family to visit

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen a sign a blood product refusal form is an example of which of the following ethical principles? Veracity Beneficence Autonomy Fidelity

autonomy

A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? Take loperamide (an antidiarrheal) as needed to control diarrhea Drink large quantities of water regular to prevent dehydration Increase the consumption of raw fruits and vegetables Consume a diet consisting of bananas, white rice, applesauce, and toast

consume a diet consisting of bananas, white rice, applesauce, and toast

A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first? apply soft limb restraints to the clients wrists administer an anti anxiety medication to the client intramuscularly (IM) cover the IV site with an elastic bandage request a prescription for a central venous catheter

cover the IV site with an elastic bandage

peristalsis

involuntary wave-like form that pushes stool through bowels

defamation of character

telling lies/spreading rumors to wrongfully hurt a person's good reputation

A nurse is teaching a group of newly licensed nursed about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice? Health care should be a right for everyone All clients should have a private room in a health care facility I plan to volunteer at the local homeless shelter on my days off I will respect a clients right to refuse a procedure

Health care should be a right for everyone

what is secondary data

info from somewhere that is not the pt

The staff nurse provides care to a stable patient who is newly diagnosed with diabetes. The patient is being prepared to discharge from the hospital. To promote efficiency, the staff nurse delegates care to a UAP. Which task must be completed by the staff nurse? Teaching the patient about symptoms of hypoglycemia Obtaining the patient's pulse rate Assisting the patient with ambulation to the bathroom Measuring the patient's blood pressure

teaching a patient about symptoms and hypoglycemia

A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take? Counsel the coworker about substance use Report the coworker to the ethics committee at the facility Ask the coworker how long they have been using substances Tell the charge nurse that the coworker might be impaired

tell the charge nurse that the coworker might be impaired

What would the expected specific gravity of urine be in a patient admitted with dehydration? 1.002 1.010 1.021 1.033

1.033

A nurse is providing postmortem care for a client. Which of the following actions should the nurse take (select all that apply) Document where the body is being moved Include the name of anyone notified in the medical record Document the date and time of death Ensure the clients belongings are accounted for Place an identification tag on a minimum of one area of the clients body

Document where the body is being moved include the name of anyone notified in the medical record document the date and time of death ensure the clients belongings are accounted for

Nonmaleficence means

do no harm

A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 min ago. Which of the following steps of the nursing process is the nurse performing? evaluation implementation analysis planning

evaluation

A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing? Evaluation Implementation Analysis Planning

evaluation

Which nursing diagnosis would be ranked as the highest priority? Constipation Pressure Ulcer Impaired Gas Exchange Impaired Tissue Integrity

impaired gas exchange

diuretics and estrogen cause urine to

increase output

A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating which of the following professional values? Integrity Human dignity Altruism Social justice

integrity

what is the most abused over-the-counter drug

laxatives

unintentional torts

negligence malpractice

ethical principals include

nonmaleficence, beneficence, fidelity, veracity, and justice

The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data? prioritized collection of assessment data organized and clusters data efficiently separates subjective and objective data identified both primary and secondary date

organized and clusters data efficiently

A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first? develop nursing diagnoses perform a physical assessment administer prescribed medications develop goals and outcomes

perform a physical assessment

medical aid in dying is

physician assisted suicide (not allowed in US)

Maslow's method of prioritization (low to high)

physiological safety love/belonging esteem self-actualization

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process evaluation implementation analysis planning

planning

analgesic (pyridium) causes urine to

turn orange

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis 2. Reassess blood pressure reading 3. Retake blood pressure after medication 4. Administer new blood pressure medication 5. Change goal to blood pressure less than 140/90

2,1,5,4,3

A nurse at a provider's office is reviewing the records of several clients. Which of the following clients should the nurse recommend as the priority for treatment. a client who has a history of hypertension and requires a yearly checkup a client who reports new chest pain a client who reports increased joint stiffness due to arthritis a client who has diabetes mellitus and need dietary instruction

A client who reports new chest pain

A nurse is providing equal care to a group of clients who have varying economic statuses. Which of the following ethical principles is the nurse demonstrating Fidelity Autonomy Justice Veracity

Justice

Which medication class will the primary care provider most likely prescribe to increase urine output in the patient with congestive hear failure MAO inhibitor Antihyperlipidemic Anticholinergic Loop diuretic

Loop diuretic

A patient is prescribed furosemide, a loop diuretic, for treatment of congestive heart failure. The nurse should monitor for which electrolyte loss? Calcium Potassium Magnesium Phosphorus

Potassium

what are close-ended questions

questions with only yes or no responses

what is involved in the planning phase

realistic goals & effective nursing interventions

what is involved in the evaluation phase

reassess and response

autonomy means

respect the pt wishes

libel

slander in writing

A nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as the priority for care? a client who received digoxin and has a heart rate of 48/min a client who received pain medication and has a respiratory rate of 14/min a client who has a urinary tract infection and temperature of 100.2 a client who has anemia and blood pressure of 118/78 mm Hg

A client who received digoxin and has a hear rate of 48/min

Which examples are objective patient cues collected from the electronic health record? Select all that apply potassium level is 3.5 mmol/L. blood pressure is 118.70 mm Hg patient reports tactile fever heart rate is 73 beats/min bowel sounds are heard in all quadrants

Potassium level is 3.5 mmol/L blood pressure is 118/70 mm Hg heart rate is 72 beats/min bowel sounds are heard in all quadrants

A nurse is caring for a client who has a terminal illness and states that they want to experience a good death, which of the following actions should the nurse take Determine the clients definition of a good death Inform the client that culture is irrelevant to an individual's perception of a good death Inform the client that a good death is not possible Communicate with the client that caregivers are prevented form providing a good death for the client

determine the clients definition of a good death

A hospice nurse is caring for a client who is hallucinating and talking to someone who is not there. Which of the following actions should the nurse take Tell the client that there is no one there Ensure client safety and prevent injury Decrease verbal interactions with the client Reorient the client to reality

ensure client safety and prevent injury

A nurse makes a nursing diagnosis of acute pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable position by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write? collaborative interdependent dependent independent

independent

What is occurring during assessment?

observation, interview, physical exam

what must be done before interventions

reassessment

antidepressants, antispasmodics, and botulinum

relax bladder muscles/control spasms

Which concept describes the process in which the nurse collects information related to a patient problem by speaking with the patient? subjective data collection focused assessment objective data collection comprehensive assessment

subjective data collection

Place the components of the planning step of the nursing process in the correct order. prioritize nursing diagnosis establish goals and outcomes select intervention create a plan of care

prioritize nursing diagnosis establish goals and outcomes select intervention create a plan of care

Muscarinic receptor antagonists

reduce urge feeling when urinating

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? a client who is scheduled for an abdominal ultrasound a client who needs a urine specimen sent to the lab a client who has audible wheezing during respirations a client who requests their routine pain medication

A client who has audible wheezing during respirations

A nurse is caring for a client who is actively dying and is discussing pain management with the clients caregiver. Which of the following information should the nurse include Pain control begins with the use of opioids The use of non pharmacological interventions is contraindicated The use of pain medications can prolong the clients death A combination of approaches is suggested to manage pain symptoms

A combination of approaches is suggested to manage pain symptoms

The nurse educator is preparing a teaching plan on preventing UTIs for a group of female college students. Which information will the nurse include in the plan? Select all that apply. Empty the bladder soon after sexual intercourse Urinate when you first feel the urge to void Wear appropriate underwear, including nylon or synthetic garments Wipe cerium are from back to front after voiding Avoid tight-fitting clothes over the groin area

Empty the bladder soon after sexual intercourse Urinate when you first feel the urge to void Avoid tight-fitting clothes over the groin area

The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patients elimination status. What is the nurse's best action? Establish a bedtime ritual for the patient Speak with the patient about past elimination habits Speak with the patients family about food choices Establish a bowel and bladder program for the patient

Establish a bowel and bladder program for the patient

A nurse is discussing the benefits of palliative care with a newly licensed nurse. Which of the following information should the nurse include Palliative care is offered to clients whose cancer has been in remission for 5 years Palliative care will increase the client's time spent in the health care facility Palliative care reduces client satisfaction Palliative care improves the client's quality of life.

Palliative care improves the client's quality of life

A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's Hierarchy of Needs. Self-actualization love and belonging safety physiological esteem

Physiological safety love and belonging esteem self-actualization

A nurse is providing education on priority setting frameworks to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework? When using this framework, clients are prioritized using a color-coded system this framework uses the least restrictive measures first as long as the clients safety is maintained when using this framework, the nurse will encourage the client to have social relationships through group interaction this framework assigns the highest priority to the situation that poses a threat to the clients physical well-being

This framework assigns the highest priority to the situation that poses a threat to the clients physical well-being

what is the Bill of Rights & Responsibility

info for pts choice of providers and plan access to emergency services (EMTALA) taking part in treatment decisions respect and non-discrimination confidentiality (privacy) of health info (HIPPA) complaints and appeals consumers responsibilities

A nurse is discussing culturally competent care with another nurse. Which of the following information should the nurse include It is culturally insensitive to talk about impending death in some cultures Most cultures agree with the use of opioids to treat pain A client's cultural information should be obtained from a coworker Culture is irrelevant when a client is making a health care decision

it is culturally insensitive to talk about impending death in some cultures

Match the intervention category to the intervention monitoring a patients temperature and skin color for fever administering antibiotics for infection as prescribed by the health care provider delegating bathing and dressing to a nursing assistant communications with health care providers independent collaborative dependent indirect

monitoring a patients temperature and skin color for fever = independent administering antibiotics for infection as prescribed by the health care provider= dependent delegating bathing and dressing to a nursing assistant= collaborative communications with health care providers= indirect

A nurse is discussing hospice care services with the caregiver of a client who is terminally ill. Which of the following information should the nurse include? Nursing support will be provided in meeting the client's daily needs, including the administration of medications The caregiver can request their temrinally ill loved one be admitted to a professional care facility fora maximum of 2 days Nurses are not allowed to become a confidant to the caregiver Nurses will have limited contact with the client and caregiver

nursing support will be provided in meeting the client's daily needs, including the administration of medications

A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? Select all that apply observe the clients lower extremities for indications of deep vein thrombosis obtain a respiratory rate for one full minute measure the clients temperature check the client for bruising obtain a blood pressure measurement

observe the clients lower extremities for indications of deep vein thrombosis measure the clients temperature check the client for bruising

The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3-4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? "bowel peristalsis is slow because you are not walking. Get more exercise during the day" "some people have a slower bowel than others, and this is nothing to be concerned about." "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel."

"Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel."

normal bowel frequency

1 time/day - 1 time/week

normal specific gravity

1.002-1.030

A nurse is assisting with client triage at the scene of a mass casualty event which of the following clients should the nurse recommend for transport first? a client who reports a possible sprained wrist and is walking around a client who has an open forearm fracture without visible drainage a client who has a respiratory rate of 6/min and no pupil response a client who has an abdominal wound that is actively bleeding

A client who has an abdominal wound that is actively bleeding

A nurse is an emergency department is caring for four clients. Which of the following clients requires mandatory reporting An adolescent client who has a fractured tibia following a football game A young adult client who is positive for tuberculosis An older adult client who has dementia, a history of falls, and bruising on their knees A preschooler who has frequent enuresis

A young adult client who is positive for tuberculosis

A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment? acute vs chronic ABCDE least restrictive/least invasive survival potential

ABCDE

what are the 5 steps of the Nursing Process

ADPIE (assessment, diagnosis, planning, implementation, evaluation)

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what the doctor said." Which of the following actions should the nurse take? Explain the procedure in detail to the client Ask the provider to discuss the procedure with the client Encourage the client to reread the consent form before signing Tell the client that the surgeon will explain it to them in the operating room

Ask provider to discuss the procedure with the client

2.A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include? (select all that apply) appropriate delegation cost of client care available resources awareness of client status support from other staff

Available resources awareness of client status support from other staff

1.A nurse is caring for a client who has been wheezing. The nurse asks an Assistive personnel to use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts A. Delegation of the right circumstance B. Delegation of the wrong task C. Delegation of the right person D. Delegation of the wrong time

B. Delegation of the wrong task

The nurse is obtaining a bowel-elimination history from an 80-year-old patient. The patient states, "Sometimes when I go to the bathroom, I push real hard, hold my breath, and plug my nose." Which action should the nurse take first? Warm the patient, "you should not hold you breath while straining." Assure the patient, "This does seem to help some people to have a bowel movement." Check the patient's medical history for heart disease or glaucoma. Notify the primary care provider that the patient has reported performing this action

Check the patient's medical history for heart disease or glaucoma

A patient who has been immobile since sustaining injuries in a motor vehicle crash complains fo constipation. The nurse encourages him to consume eight to ten 8-ounce servings of fluid daily. Which fluid should the patient avoid because of the diuretic effect? Select all that apply. Cranberry juice Water Coffee Ginger ale Tea

Coffee Tea

Which task may be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. Irrigating a newly created colostomy Collecting and testing a stool sample for occult blood Digitally removing stool as a result of a fecal impaction Assisting with placing a fracture pan on an immobile patient Changing a preexisting, stable ostomy appliance

Collecting and testing a stool sample for occult blood Assisting with placing a fracture pan on an immobile patient Changing a preexisting, stable ostomy appliance

4. A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? A. critical thinking is the foundation for clinical decision making B. Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." C. Critical thinking is the visible or observed outcome while using evidence-based practice." D. Critical thinking is necessary for the nurse to collect objective client data."

Critical thinking is the foundation for clinical decision making

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? Decreased cardiac output related to altered myocardial contractility as evidence by pain in chest rating 6/10. Patient needs a low-fat diet related to inadequate heart perfusion. Offer a low-fat diet because of heart problems. Acute heart pain related to discomfort.

Decreased cardiac output related to altered myocardial contractility as evidence by pain in chest rating 6/10.

What is the most significant change in kidney function that occurs with aging? Decreased glomerular filtration rate Increased renal mass Proliferation of micro-blood vessels in renal cortex Formation of urate crystals

Decreased glomerular filtration rate

A nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. Which of the following actions should the nurse take to provide the expected standard of care? Document that the medication was not administered Document that the client is not experiencing pain Contact the provider to change the PRN prescription Fill out an incident report about the situation

Document that the medication was not administered

A nurse is caring for a client who is actively dying. Which of the following actions should the nurse take for alterations in breathing pattern? Withhold opioids because they can hasten the clients death Report changes in the respiratory pattern to the health care provider as they occur Educate the family about the expected respiratory changes Inform the family that oxygen therapy has no benefit

Educate the family about the expected respiratory changes

A novice nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? "Evaluative measures are multiple-page documents used to evaluate nurse performance." "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse. "Evaluative measures are objective views for completion of nursing interventions."

Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals

A nurse stops at the side of the road to provide care to a person involved in a motor vehicle crash. Which of the following protects the nurse from liability when administering care at the scene of an accident? Whistleblower protection Good Samaritan law Torts Emergency medical treatment

Good Samaritan law

A nurse is providing privacy for a client who has incontience. The nurse is demonstrating which of the following professional values? Human dignity Altruism Social justice Autonomy

Human dignity

how do we prioritize

Maslow's pyramid

who pays for hospice

Medicare Medicaid private insurance

A nurse is caring for a client who is actively dying and notes the client's feet are purple and marbled. Which of the following findings should the nurse expect The client's feet are warm to the touch The client feels pain in the affected extremity The client has a fever Mottling is visible on the client's legs

Mottling is visible on the client's legs

what is involved in making a 3 part statement

PES (problem r/t etiology AEB symptoms)

A nurse is completing an assessment. Which findings will the nurse report as subjective data? ( Select all that apply.) patients temperature patients wound appearance patients states "i'm excited to be discharged patient pacing the floor while awaiting test results patients states " I am scared of what my test results will show"

Patient states " I'm excited to be discharged" patients states "I am scared of what may test result will show"

what are the components of a goal statement

Subject (The Patient) Action Verb (ex. Walk, Move, Dress) Performance criteria (ex. 10 feet) Needs to be realistic Target Time (in 24 hr) Special Conditions (Assistance, resources)

Interventions to prevent Urinary tract infection in children include all of the following except Cleaning genitalia from front to back ' Drink acid fluids Take warm bubble baths Void frequently

Take warm bubble baths

A nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. Which of the following is the provider violating? The emergency medical treatment and labor act The health insurance portability and accountability act of 1996 (HIPAA) Tort law Good Samaritan laws

The emergency medical treatment and labor act

A nurse is caring for a client who is actively dying. The clients caregiver asks the nurse about the clients noisy respirations. Which of the following information should the nurse include? They can be an indication of approaching death Deep suctioning is effective in removing trapped secretions Turning the clients head to the side can assist with drainage Medications can be administered to help dry up the secretions The client is unable to clear secretions themselves

They can be an indication of approaching death turning the clients head to the side can assist with drainage medications can be administered to help dry up the secretions the client is unable to clear secretions themselves

The nurse would expect which sings and symptoms for a patient with a suspected Urinary Tract Infection (UTI)? Select all that apply. Urinary frequency Dysuria Polyuria Upper abdominal pain Foul-smelling urine

Urinary frequency Dysuria Foul-smelling urine

A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote heating? Yogurt Oatmeal Broccoli Pasta

Yogurt

battery

action of doing harm

types of nursing diagnoses

actual, risk (potential), possible

what do dependent interventions require

an order from the physician/doctor

LPNs can NOT...

assess or educate

how do we collect info?

assessing, questioning, pt Hx, pt chart

what order should an RN perform the steps of the nursing process? evaluation assessment nursing diagnosis/analysis planning implementation

assessment nursing diagnosis/analysis planning implementation evaluation

what is the biggest part of the Dying Persons Bill of Rights

autonomy, dignity, and respect

justice means

be fair

A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's airway and breathing status. Which of the following assessments should the nurse perform next? body temperature abdominal contour skin integrity blood pressure

blood pressure

important step in postmortem care

call organ procurement center regardless of pt donation status

lab values to check for UTI

clarity, odor, hemoglobin, leukocytes, and bacteria

A nurse is reviewing methods created to assist nurses in using evidence based practice. Which of the following is a NCSBN model that can assist the nurse with critical thinking and decisions making? clinical judgment critical thinking clinical reasoning SMART goal

clinical judgment

slow peristalsis causes

constipation

Quasi-Intentional torts

defamation of character libel

Kubler-Ross 5 stages of greif

denial, anger, bargaining, depression, acceptance

fast peristalsis causes

diarrhea

negligence

failing to do something

nephrons

filtering units of kidneys

normal stool appearance

formed, soft, 75% water

veracity means

give accurate info

invasion of privacy

going against HIPPA guidelines

malpractice

harm to pt and/or outside scope of practice

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? Select all that apply. Increase fiber intake Increase water consumption Refrain from smoking Decrease physical exercise Refrain from alcohol

increase fiber intake increase water consumption

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion? Select all the apply inspection inference creativity inductive reasoning

inference creativity inductive reasoning

A nurse is caring for a client who is actively dying. The client's caregivers state they are interested in donating the clients organs. Which of the following actions should the nurse take? Discuss the process of organ donation with the caregiver Make a referral to an organ procurement organization Inform the caregiver that only the client can give authorization for organ donation Notify the health care provider since they are responsible for discussing organ donation with the family member

make a referral to an organ procurement organization

A nurse is discussing palliative care with a client who has colon cancer. Which of the following information should the nurse include Palliative care is limited to a specific time frame Palliative care uses a holistic approach Palliative care is provided after the client has stopped curative treatment methods Palliative care is offered to clients who have non-life-threatening illnesses

palliative care uses a holistic approach

Atherosclerosis

plaque build up in arteries (reduces blood flow to kidneys)

what is involved in the implementation phase

preform/delegate planned interventions

what are indirect care interventions

preformed with others

what are direct care interventions

preformed with the pt

beneficence means

prevent harm/do good

ethical dilemmas

problems with more than 1 choice and stems from differences between decision makers

anticholinergics effect urine by

promoting reabsorption

A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of maslow's Hierarchy of needs love and belonging self actualization safety self-esteem

self-esteem

what factors could lead to a lack of goal achievement

pt attitude/behavior, lack of resource, etc.

A nurse is planning care for a client who is terminally ill and speaks a different language than the nurse. Which of the following actions should the nurse take Use a family member as a translator Allow assistive personnel to translate for the client Use the health care facility's interpreter services Download a smartphone application from the internet

use the health care facility's interpreter services

A nurse is caring for a client who is an acute care facility. The nurse should recognize that the client's care requires clinical reasoning when it is complicated by which of the following factors? Select all that apply complex clinical situations ongoing client and family concerns cost of health care decreased need for advanced health care practitioner intervention availability of computerized medical records

complex clinical situations ongoing client and family concerns

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? "The patient forgets where the bathroom is located due to dementia" "the patient is angry about the dementia diagnosis." "the patient is losing sphincter control due to the dementia." " The patient wants to leave the Hosptial."

"the patient is losing sphincter control due to the dementia."

The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patients elimination status. What is the nurse's best action? Speak with the patients family about food choices Establish a bowel and bladder program for the patient Speak with the patient about past elimination habits Establish a bedtime ritual for the patient

Establish a bowel and bladder program for the patient

A nurse is reviewing hospice care services with a group of newly hired nurses. Which of the following information should the nurse include Hospice services are terminated with the death of the client Hospice services are limited to serving the client Hospice care is an interdisciplinary team effort Hospice care volunteer services are limited to direct client care

Hospice care is an interdisciplinary team effort

Which nursing activity is most reflective of the evaluation phase of the nursing process? administering pain medication prior to changing a complex wound dressing obtaining patines BP 30 minutes after administering BP medication reporting three patient falls in the past month on the nursing unit teaching the patient how to perform daily finger sticks for blood glucose readings

obtaining patients blood pressure 30 minutes after administering BP medication

A nurse is grieving following the death of a client who had a terminal illness and is having difficulty sleeping and concentrating. Which of the following actions should the nurse take? Avoid talking with more experienced nurses about copying with the death of a client Refrain form attending the client's funeral Participate in an exercise program Distance themselves from the clients family

participate in an exercise program

The nurse identifies a nursing diagnosis of urinary incontinence in an older adult patient admitted after a stroke. Urinary incontinence places the patient at risk for which complication? Skin breakdown Urinary tract infection Bowel incontinence Renal calculi

skin breakdown

antiacids, iron, narcotics, and antimotility drug (Lomotil) cause peristalsis to

slow, creating constipation

antibiotics and laxatives cause peristalsis to

speed up, causing diarrhea

A nurse is discussing the concept of spirituality with a newly licensed nurse. Which of the following information should the nurse include? Spirituality can be easily defined Spirituality is similar for all clients Religion and spirituality are interchangeable Spirituality focused on the significance and purpose of life

spirituality focused on the significance and purpose of life

hospice requirements

terminal illness and 2 physicians have decided only 6mo left to live

A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority? The client reports dizziness when standing the client has not had a bowel movement in 3 days the client has non-pitting edema in the lower extremities the client has several scratch marks on their abdomen

the client reports dizziness when standing

factual documentation

F- factual and objective A- accurate C- complete T- timely U- unusual occurrences A- assessment data L- legal documents

A day after abdominal surgery, a postoperative patient on the surgical unit says to the nurse, "I'm having a problem with a lot of gas. Maybe it's the food I'm eating." What is the appropriate response by the nurse? Select all that apply. "if the problem continues after you go home, you'll need to avoid gas-producing foods, such as beans" "Let's get you out of bed and walking more. This can help with your gas." "When was your last bowel movement? You may be a bit constipated." "I understand. I'll have to call the doctor for insertion of a rectal tube." "we may need to get you ready to go back to surgery to fix this problem."

"if the problem continues after you go home, you'll need to avoid gas-producing foods, such as beans" "Let's get you out of bed and walking more. This can help with your gas." "When was your last bowel movement? You may be a bit constipated."

Which term describes subjective indications of a disease or a change in condition as perceived by the patient? symptoms signs conditions assessment

symptoms

A nurse is planning care for clients. Which of the following tasks can the nurse delegate to an assistive personnel (AP)? Teaching a client who is preoperative how to use an incentive spirometer Obtaining a blood pressure for a client who is to be discharged later in the day. Providing tracheostomy care for a client Assessing a client who just returned from surgery.

obtaining a blood pressure for a client who is to be discharged later in the day

A nurse uses the accepted rights of delegation when providing care. Which "rights" did the nurse use? ( Select all that apply.) task person direction supervision circumstances cost-effectiveness

task person direction supervision circumstances

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? a client who is scheduled for an abdominal ultrasound a client who needs a urine specimens sent to the lab a client who has audible wheezing during respirations a client who request routine pain medications

A client who has audible wheezing during respirations

Which instruction should the nurse give the parent to assess a 2-year-old child for pinworms? Press clear cellophane tape against the rectum as soon as the child wakes up Collect freshly passed stools for the diaper by using a wooden specimen blade Insert a cotton-tipped swab 2 inches into the rectum to look for visible worms Do not let the child eat after midnight for an x-ray in the morning

Press clear cellphone tape against the rectum as soon as the child wakes up

Steps to take when making an ethical decision

1)Identify whether the issue is indeed an ethical dilemma. 2)Gather as much relevant information as possible about the dilemma. 3)Reflect on your own values as they relate to the dilemma. 4)State the ethical dilemma, including all surrounding issues and the individuals involved. 5)List and analyze all possible options for resolving the dilemma and review the implications of each option. 6)Select the option that is in concert with the ethical principle that applies to this situation, the decision makers values and beliefs, and the profession's values for client care. 7)Select the option that is in concert with the ethical principle that applies to this situation, the decision makers values and beliefs, and the profession's values for client care. 8)Justify selecting the one option in light of the relevant variables. 9)Apply this decision to the dilemma and evaluate the outcomes. 10)If a decision can't be reached the Ethics Committee will address unusual or complex ethical issues

When conducting a health history assessment, which information would be viewed as most important as related to the patient's elimination status? (Select all that apply.) List of medications taken by patient Time of day patient defecates Changes in color, consistency, or odor of stool or urine Discomfort or pain with elimination Recent changes in elimination patterns Patients preferences for toileting

List of medication taken by patient changes in color, consistency, or odor of stool or urine discomfort or pain with elimination recent changes in elimination patterns

types of advance directives

living will & power of attorney