adult health practice problems
A client who is preparing to sign an informed consent form states, "Remind me again of what exactly are they going to do to me during this abdominal surgery." Which nursing action is appropriate? a. Contact the surgeon. b. Explain the procedure. c. Have the client sign the form. d. Inform the anesthesia provider.
a
A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? a. "Please allow the client to push the button when needed." b. "Please don't touch any equipment in the client's room." c. "Thank you. I am sure the client appreciated that." d. "The client is asleep and is not in pain."
a
A client with opioid substance use disorder is having major surgery. Which approach to pain control does the nurse anticipate? a. More than usual pain medication b. Exclusive use of non-opioid drugs c. Restraints to keep pain controlled d. Frequent administration of naloxone
a
A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? a. Intravenous b. Oral c. Rectal d. Transdermal
a
A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? a. Acetaminophen b. Hydromorphone c. Midazolam d. Oxycodone
a
The nurse has assessed a client with elevated blood pressure and connected this presentation to an existing history of hypertension and nonadherence to the antihypertensive medication regimen. During which process of the Clinical Judgment Measurement Model will the nurse conduct this action? a. Analyze Cues b. Prioritize Hypothesis c. Take Action d. Evaluate Outcomes
a
The nurse is caring for a client at end of life. What is the nurse's priority for the client's care? a. Increase comfort. b. Maintain breathing. c. Ensure adequate nutrition. d. Promote coping
a
The nurse is caring for a client who reports a cough, fever, and congestion for three days. During which process of the Clinical Judgment Measurement Model will the nurse consider this information first? a. Recognize Cues b. Generate Solutions c. Take Action d. Evaluate Outcomes
a
The nurse is caring for a client with hypervolemia. Which assessment data indicates a potential decline in condition? a. Neck veins are distended in the sitting position. b. Breath sounds can be heard in the right lower lung lobe. c. Weight is unchanged from yesterday's daily weight. d. The client reports feeling hungry and somewhat thirsty.
a
The nurse is caring for a client with hypokalemia. Which assessment data indicates to the nurse that the treatment is effective? a. The client reports having a bowel movement daily. b. A two lb weight gain during the past week is noted. c. Current ECG shows an inverted T wave. d. Fasting blood glucose level is 106 mg/dL.
a
The nurse is caring for an older client living independently in the community. This morning the client was admitted for cellulitis of the right foot due to a spider bite. For which complication is this client most at risk? a. Decreased mobility b. Inadequate nutrition c. Impaired cognition d. Impaired elimination
a
The nurse is taking a history for a nonbinary client. Which client statement will the nurse address as the priority? a. "Sometimes I feel like no one understands me." b. "I've been thinking about chest nullification surgery." c. "Binding my chest has started to become a bit uncomfortable." d. "I want to talk with the provider about taking micro doses of hormones."
a
The nurse provides postsurgical teaching to a client who has had shoulder surgery. Which client statement indicates that teaching has been effective? a. "I will restrict activities until I see the surgeon for follow up." b. "It is necessary to wear a sling only if I am ambulating." c. "Some bleeding from the incision is normal for several weeks." d. "The wound will completely heal in a month or so."
a
Which client situation reflects the health care system of Managed Care? a. A client receives an annual physical where the cost has been predetermined as $80. b. A client with abdominal pain is admitted to a hospital for 24 hours of observation. c. A client sees a designed family physician who coordinates all aspects of the client's care. d. A client obtains vaccinations at a local community health center that is close to home.
a
Which phrase reflects the definition of critical thinking when a nurse is providing care for a client? a. Using logic and reason to identify approaches to care b. Making informed and responsible clinical decisions c. Assessing, analyzing, planning, intervening, and evaluating d. Using nursing knowledge to assess, prioritize, and determine care
a
a client has returned to the medical-surgical floor from the PACU following an appendectomy. which action would the nurse take? a. monitor temperature every 4 hours b. bind incision tightly to prevent bleeding c. apply heat to the abdomen to promote comfort d. encourage favorite foods to promote return of bowel function
a
the grasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. which action would the nurse take first? a. determine the oxygen saturation b. measure pulse and blood pressure c. notify the rapid response team d. apply humidified oxygen by nasal canula
a
the nurse is caring for a client who is nonbinary. which nursing action is appropriate regarding appropriate pronoun use? a. ask which pronounds the client uses b. implement use of "she/her" pronouns, as the client's sex assigned at birth is female c. automatically use "they/them" since the client reports being nonbinary d. document that any pronouns the nurse uses are acceptable to use at this time
a
what is the most appropriate nursing intervention for a postoperative client who has delirium? a. provide a safe environment for the client b. reorient the client to reality c. use validation therapy d. observe for delusions and hallucinations
a
The nurse is caring for a client who has a rare condition that causes decreased clotting ability. For what assessment findings would the nurse monitor? (Select all that apply.) a. Melena b. Hematuria c. Ecchymoses d. Deep vein thrombosis e. Decreased prothrombin time
a, b, c
The nurse is teaching a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.) a. "I must keep the stockings on at all times." b. "My stockings are loose so they do not hurt my legs." c. "I will wear the stockings when I feel like it." d. "These stockings help promote blood flow." e. "I feel like these stockings are somewhat compressing my legs."
a, b, c
the nurse is care for a client who has returned from an exploratory laparotomy under general anesthesia. which of the following actions would the nurse include? select all that apply a. teach to splint the abdomen when coughing b. offer ice chips to moisten mucous membranes c. encourage coughing and deep breathing every hour while awake d. provide the call light and state to use it if needing to get out of bed e. remind to perform foot and ankle exercises one per shift until discharge
a, b, c, d
The nurse is providing health teaching at a health fair about preventing influenza. What adult groups are at risk for contracting this disease due to altered immunity? (Select all that apply.) a. Older adults b. Adults with substance use disorder c. Nonimmunized adults d. Adults with chronic illness e. Adults who do not practice a healthy lifestyle
a, b, c, d, e
Which factor does the nurse identify that influences client outcomes? (Select all that apply.) a. What the individual client believes about health b. The culture to which the client identifies c. Health policy legislation at the state and national level d. Technology that is available in the local community health center e. Collaboration between members of the interprofessional health care team f. The application of systems thinking to care of clients
a, b, c, d, e, f
The nurse is caring for a client with impaired tissue integrity. Which foods would best help promote tissue healing? (Select all that apply.) a. Oranges b. Meats c. Cereal d. Eggs e. Cheese
a, b, d, e
Which factor does the nurse identify that can increase stress for a transgender or nonbinary people? (Select all that apply.) a. Living in poverty b. Feeling misunderstood c. Having multiple friends d. Needing to teach health care providers e. Experiencing employment discrimination
a, b, d, e
Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) a. Respecting the client's preference about treatment options b. Designing nursing care with a focus on keeping the client safe c. Including the client in discussions about dietary choices d. Referring to a nursing journal to consider trends in care e. Participating on a committee that is evaluating the newest bar-code scanner f. Using data collected over the past quarter to determine if and how nursing care should change
a, c
Which nurse is recognized as an advance practice registered nurse (APRN) by the American Nurses Association? (Select all that apply.) a. Certified Nurse Midwife b. Clinical Nurse Educator c. Clinical Nurse Specialist d. Certified Nurse Practitioner e. Certified Registered Nurse Anesthetist
a, c, d, e
The nurse prepares to teach a client at risk for increased clotting about interventions to prevent clots. What health teaching would the nurse include? (Select all that apply.) a. "Drink plenty of fluids, including water." b. "Report any unusual bleeding or bruising." c. "Avoid crossing your legs when sitting." d. "Walk around frequently as much as you can." e. "Seek smoking cessation programs if needed." f. "Avoid prolonged periods of sitting."
a, c, d, e, f
the nurse is caring for a client who has been on mechanical ventilation for the past seven weeks. for which of the following complications is the client at risk due to immobility? Select all that apply. a. muscle atrophy b. arterial thrombosis c. urinary calculi d. disease osteoporosis e. change in sleep-wake cycle f. constipation
a, c, d, e, f
which of the following nursing actions increase health equity for transgender and nonbinary clients? Select all that apply a. ask what name and which pronouns the client uses b. determine gender identity based on clothing worn c. seek to understand the individual experience of the client d. apologize several times if the wrong name is used when addressing the client e. explain how the health history and assessment are affected by gender identity
a, c, e
which of the following electrolytes are most affected by low magnesium levels? select all that apply a. calcium b. chloride c. hydrogen d. potassium e. sodium
a, d
Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) a. Collects information about how client sustained an injury. b. Compares temperature at 0600 with temperature taken at 1200. c. Sets a goal for client to resume normal activities within four weeks following surgery. d. Administers IV furosemide 40 mg as prescribed. e. Notes pressure injury of 2 inches by 1 inch on sacrum. f. Contacts health care provider after obtaining blood pressure of 200/100.
a, e
A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? a. "I will discuss cancelling your medication order with your health care provider." b. "That sounds like a great plan; can you tell me more about it?" c. "That sounds like a wonderful idea; and I think it will definitely work!" d. "Your plan will not work; people with your type of pain need opioids."
b
After receiving the change-of-shift report, which client will the nurse assess first? a. A 45 year old with a nasogastric (NG) tube with dry oral mucosa and reports feeling very thirsty. b. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. c. A 67 year old with nausea and vomiting who reports abdominal cramps. d. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL.
b
The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? a. "I always assess older adults for present pain." b. "Older adults typically believe that expressing pain is acceptable." c. "Older adults are at a very high risk for undertreated pain." d. "Older adults usually believe that pain is irrelevant and is to be expected."
b
The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? a. "I will ask his oncologist about your question." b. "Let's ask your father about your request." c. "No, his pain relief is more important than your concerns." d. "Yes, this is a valuable way for all of you to make needed adjustments."
b
The nurse assesses a client's wound 24 hours postoperatively. Which finding requires the nurse to contact the surgeon? a. Crusting along the incision line b. Warmth and swelling around the incision c. Sanguineous drainage at the suture site d. Serosanguineous drainage on the dressing
b
The nurse has assessed a client with fever, well-managed hypertension, and controlled Type 2 diabetes, and determined that the fever is of the most urgency to address. During which process of the Clinical Judgment Measurement Model will the nurse conduct this action? a. Analyze Cues b. Prioritize Hypothesis c. Take Action d. Evaluate Outcomes
b
The nurse is caring for a client diagnosed with impaired cognition. What is the nurse's priority for care at this time? a. Maintain mobility. b. Ensure safety. c. Improve cognition. d. Provide comfort.
b
The nurse is caring for a client who had a stroke and now has difficulty holding a fork and spoon. With which member of the interprofessional team will the nurse most closely collaborate to assist the client? a. Physical therapist b. Occupational therapist c. Speech language pathologist d. Registered dietitian nutritionist
b
The nurse is caring for a client whose serum potassium level is 2.0 mEq/L (mmol/L). Which assessment is most important? a. Measuring blood pressure b. Assessing lung sounds c. Reviewing electrocardiogram d. Auscultating bowel sounds
b
The nurse is caring for an older adult client with dehydration. Which assessment will the nurse perform to determine whether the client is safe for independent ambulation? a. Assessing the tongue for dryness of mucous membranes b. Comparing orthostatic blood pressure measurements c. Ensuring the most recent serum potassium level d. Comparing the radial pulse with the apical pulse
b
The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? a. Inpatient Care b. Community Health Center c. Long Term Care d. Medical Home
b
The nurse is planning care for a client with pneumonia. During which process of the Clinical Judgment Measurement Model will the nurse conduct this action? a. Recognize Cues b. Generate Solutions c. Take Action d. Evaluate Outcomes
b
Which action does the nurse implement for a client with wound evisceration? a. Apply direct pressure to the wound. b. Cover the wound with a sterile, warm, moist dressing. c. Irrigate the wound with cool, sterile saline. d. Replace organs protruding into the opening.
b
Which client does the nurse identify at greatest risk for slow wound healing? a. Client with STI b. Client with diabetes c. Client who smokes 1 pack of cigarettes daily d. Client with hypertension controlled by medication
b
the nurse is caring for a client on Friday. the client has a short peripheral intravenous catheter (short PIVC) inserted earlier in the week on Tuesday. which action would the nurse take? a. replace the short PIVC b. assess the PIVC insertion site c. discontinue the short PIVC d. convert the short PIVC to a saline lock
b
the nurse is caring for a client who had surgery recently. when the client asks for pain medication an hour before it is due, which nursing response is the priority? a. "pain medication is scheduled to be given 1 hour from now" b. "can you describe the pain you are having and rate it on a 0-10 scale?" c. "I can help you begin a pain diary so we can see trends when your pain worsens" d. "lets try some relaxation exercises to help address the discomfort you are feeling"
b
the nurse is caring for a client who has a serum potassium level of 2.9 mEq/L. which assessment is appropriate? a. asking about the use of sugar substitutes b. determining what drugs are taken daily c. assessing for Chvostek sign d. assessing for a history of kidney disease
b
the nurse is caring for a client who is experiencing myocardial infarction and reports intense pain in the jaw area and pressure in the chest wall. how would the nurse document the clients pain? a. the client describes localized pain in the jaw area and reports pressure in the chest wall. b. the client describes referred pain in the jaw and reports localized pressure in the chest wall c. the client describes projected pain from the chest wall into the jaw area d. the client describes radiating pain in the jaw and referred pressure in the chest wall.
b
the nurse is caring for a client with COVID-19 which nursing action reflects systems level thinking? a. place client in prone position as ordered b. compare hospital infection rate with state infection rate c. ask if there are cultural or spiritual needs while hospitalized d. reference agency policy when explaining visiting hours to family members
b
the nusre has recieved orders for patient-controlled analgesia for four clients. which order requires the nurse to contact the provider? a. a 47 yo client with endometriosis immediately following total abdominal hysterectomy b. a 56 yo client with early-onset dementia 1 hour post total hip arthroplasty c. a 29 yo client with diabetes 6 hours postappendectomy following rupture d. a 60 yo client with colon cancer who is 12 hours post colon resection
b
The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) a. Picking at skin or clothing b. Breathing pattern c. Vocalizations d. Facial expression e. Body language
b, c, d, e
The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) a. "Your health care provider can prescribe cannabis for you." b. "Medical cannabis is a controlled substance in the United States." c. "Side effects of cannabis can include dizziness and increased appetite." d. "The psychoactive component of medical cannabis is removed." e. "Federal and state law often vary in the legality of medical cannabis use."
b, c, e
A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) a. Assistance by the client with the dressing change b. Distraction c. Epidural analgesic d. Music therapy e. Premedication
b, d, e
The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.) a. Pain rated as a 4 on a scale of 0-10 b. Referred pain c. Sharp pain d. Localized pain e. Radiating pain f. Negative vocalization
b, d, e
A 60-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen every 8 hours." How does the nurse respond? a. "Aspirin would be a better, more effective choice for pain relief." b. "More acetaminophen is needed to provide effective pain relief." c. "Acetaminophen is the first-line drug to treat pain associated with osteoarthritis." d. "You will need to have routine blood draws to monitor clotting time."
c
A client has just undergone a surgical procedure with general anesthesia. Which assessment finding requires nursing intervention? a. Pain at the surgical site b. Awakens upon verbal stimuli c. Snoring sounds when inhaling d. Reports sore throat upon swallowing
c
A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? a. Decrease the client's standard pain medication dose. b. Give the client a placebo and monitors the outcome. c. Administer the pain medication as requested. d. Withhold the pain medication.
c
A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? a. Addiction b. Tolerance c. Physical dependence d. Pseudoaddiction
c
A nonbinary client with documented directives has died. When a family member states, "I want to put their birth name on their obituary", which nursing response is appropriate? a. "I will communicate your desire to the health care provider." b. "Why don't you want to respect their choice about names?" c. "Your loved one's directives indicate their name to be used." d. "Because they have died, their birth or chosen name are fine to use."
c
During a preoperative assessment, which client statement requires further nursing assessment regarding surgical risks? a. "I take a multivitamin daily." b. "I drink a glass of wine daily." c. "I had a heart attack a few months ago." d. "I quit smoking 2 years ago."
c
The nurse is administering medications to a client on a medical-surgical unit following a knee replacement. During which process of the Clinical Judgment Measurement Model will the nurse conduct this action? a. Analyze Cues b. Prioritize Hypothesis c. Take Action d. Evaluate Outcomes
c
The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? a. Call the care provider for a change in the medication order. b. Change the order to every 6 hours rather than every 4 hours. c. Administer a dose of naloxone slow IV push. d. Perform a cognitive assessment on the client.
c
The nurse is caring for a client who has delirium. Which statement is correct regarding this health problem? a. Delirium takes months to years to develop. b. The cause of delirium is not known. c. The focus of managing delirium is to treat the cause. d. Validation therapy is the best approach for delirium.
c
The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? a. Administer pain medication. b. Assess the level of pain. c. Accept the client's report of pain. d. Call the health care provider for a medication order.
c
The nurse is caring for a client with suspected fluid overload. Which action will the nurse take first? a. Assess blood pressure. b. Measure intake and output. c. Elevate the head of the bed. d. Check for dependent edema.
c
The nurse is conducting an assessment for a client who is experiencing severe pain after surgery to repair a hip fracture. What client finding would the nurse expect? a. Decreased blood pressure b. Respiratory depression c. Elevated heart rate d. Constricted pupils
c
The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? a. 3:30 p.m. b. 4:00 p.m. c. 4:30 p.m. d. 7:00 p.m.
c
The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? a. Physical therapist b. Licensed social worker c. Occupational therapist d. Assistive personnel
c
When a nonbinary client asks, "Can I use hormone therapy to modify my appearance", which nursing response is appropriate? a. "You look fine the way you are." b. "Why do you want to change your appearance?" c. "Microdosing hormone therapy can be discussed with your provider." d. "No, hormone therapy is only appropriate for transitioning from MtF or FtM."
c
Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? a. Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable b. Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain c. Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care d. Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief
c
Which client will the nurse consider at greatest risk for dehydration? a. A 25-year-old female taking oral contraceptives b. A 31-year-old male who has frequent esophageal reflux c. A 75-year-old female with chronic back pain d. A 73-year-old male who has a vitamin deficiency
c
Which nursing action reflects the process of Prioritize Hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? a. Administering amlodipine 5 mg orally once daily b. Obtaining vital signs every four hours and noting a client's blood pressure as 130/90 c. Determining that a new blood pressure reading of 190/100 requires intervention now d. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake
c
Which teaching will the nurse provide to a transgender client who has been prescribed oral estrogen for the first time? a. "Side effects often include weight loss." b. "You may feel sedated when taking estrogen." c. "The risk for venous thromboembolism is increased." d. "Before applying a new patch, remove the used patch."
c
the nurse is caring for a 44 yo client who requires IV fluid replacement. the nurse has one unsuccessful attempt when inserting a short peripheral IV catheter. what action would the nurse take next? a. consult the IV therapy team b. ask a colleague to attempt c. attempt insertion a second time d. notify the provider of limited IV access
c
the nurse is caring for a cliemnt with a cematocrit of 57% and a sodium level of 149 mEq/L. how would the nurse interpret this data? a. the client is most likely anemic b. the client has an actual increase in sodium intake c. the client is experiencing relative hypernatremia d. the client is experiencing actual hyponatremia
c
the nurse is caring for an older client who reports having diarrhea for the past three days. which potential complication is most concerning for this client? a. impairment of tissue integrity b. weight loss c. fluid imbalance d. decreased nutrition
c
A MtF client has undergone a vaginoplasty. Which action will the nurse take while the client is on a medical-surgical recovery unit? (Select all that apply.) a. Begin immediate dilation therapy. b. Remove the vaginal packing on day 2. c. Administer subcutaneous heparin as ordered. d. Check for blood pooling underneath the client. e. Apply an ice pack to the perineum for 30 minutes each hour.
c, d
A client who wishes to achieve masculinization of the body and cessation of menses asks about hormones. Which hormone therapy will the nurse discuss with the client? (Select all that apply.) a. Estrogen b. Progestin c. Testosterone d. Progesterone e. Luteinizing hormone-releasing hormone
c, d
The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.) a. Age 50 years b. Anesthesia complications experienced by sister c. History of diabetes mellitus d. Ten pounds (4.5 kg) over ideal body weight e. Taking methylprednisolone therapy
c, e
Which component does the nurse identify as characteristic of behavioral determinants of health for clients? (Select all that apply.) a. Policy reform b. Cost of health care c. What "health" means to each person d. Presence of insurance coverage for health care e. Actions a person is willing or able to take toward health
c, e
A MtF client asks the nurse if treatments are available to change the pitch of their voice. The nurse will refer the client to which member of the interprofessional team? a. Audiologist b. Nurse practitioner c. Occupational therapist d. Speech-language pathologist
d
A client is scheduled to have a temporary colostomy placed. How will the nurse document this type of surgery? a. Cosmetic b. Curative c. Diagnostic d. Palliative
d
A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? a. Encouraging diversional activities b. Incorporating activities of daily living as soon as possible c. Teaching key points of the relaxation response d. Using preemptive analgesia
d
An older adult's partner tells the nurse that the client wants life support; the client has a DNR order in place. Which action will the nurse take? a. Call the legal department to draft a change in paperwork. b. Document the conversation in the electronic health record. c. Thank the partner for sharing the parent's desires. d. Talk to the client to confirm that they wish to keep the DNR.
d
The nurse has created a plan of care and administered medications and treatments for a client with an asthma exacerbation. During which process of the Clinical Judgment Measurement Model will the nurse determine if these actions were effective? a. Analyze Cues b. Prioritize Hypothesis c. Take Action d. Evaluate Outcomes
d
The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? a. "Did someone do this to you?" b. "Does it feel like sharp pain?" c. "Is the pain really that bad?" d. "When does the pain occur?"
d
The nurse is caring for a client who has a serum potassium level of 6.9 mEq/L (mmol/L). Which action will the nurse take first? a. Provide a potassium-restricted diet. b. Administer potassium excreting diuretics. c. Teach the client foods to avoid. d. Initiate continuous cardiac monitoring.
d
The nurse is caring for a homeless client in the Emergency Department and determines that the client has inadequate nutrition. Which risk factor would the nurse suspect most likely contributes to this client's nutritional status? a. Obesity b. Substance use c. Hypothyroidism d. Food insecurity
d
The nurse is caring for an older adult who has received treatment for dehydration. Which assessment finding indicates to the nurse that treatment was successful? a. Client reports feeling hungry. b. Pulse pressure has decreased. c. Hematocrit is 58% (0.58 volume fraction). d. Hourly urine output is greater than 15 mL.
d
The nurse is educating a client who is about to undergo lung surgery under general anesthesia. Which client statement requires further nursing teaching? a. "I will wake up with a tube in my mouth and throat." b. "There will be a bandage on my chest after surgery." c. "My family will not be able to see me right away." d. "My pain will be gone while I am receiving pain medicine."
d
The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? a. "The landlord of my apartment is putting in an access ramp for wheelchairs." b. "I work with a lot of toxic chemicals in my job." c. "Because I live on the bus line, I can ride over to park if I want to get fresh air." d. "The grocery store in my neighborhood went out of business."
d
The nurse is providing preoperative care for a client who is having a right below-the-knee (BKA) amputation. Which action will the nurse take as the priority? a. Confirm the right BKA surgery with the surgeon. b. Document the time surgery began in the client's health record. c. Verify with the client that a right BKA procedure will be performed. d. Witness the client marking their right knee site before anesthesia, in the surgeon's presence.
d
The nurse notes that the Jackson-Pratt drain of a MtF client who underwent vaginoplasty yesterday has collected 30 mL in a 24-hour period. Which action will the nurse take? a. Prepare for emergency surgery. b. Remove the Jackson-Pratt drain. c. Contact the health care provider. d. Document the finding in the health record.
d
which action would the nurse take to demonstrate systems thinking? a. reading a journal article to enhance one's understanding of a specific disorder b. providing patient-centered care to all individuals, recognizing their uniqueness c. engaging in a professional development activity to earn continuing education credit d. using information from individual client care to improve outcomes at a macro level
d
which client would the nurse monitor closely for the development of respiratory acidosis? a. client who continually takes antacids b. client recieving IV normal saline bolus c. client whose urinary output has increased d. client with rid bractures following a motor vehicle accident
d
which nursing action reflects implementation of systems level thinking? a. conducting a respiratory assessment on a newly admitted client b. documenting a labratory finding of COVID-19 in the electronic health record c. notifying the health care provider about a change in breathing status of the client d. participating in a quality improvement project about appropriate use of personal protective equipment agency wide
d
Which term is associated with a person's gender identity? a. Gay b. Lesbian c. Intersex d. Bisexual e. Transgender
e
