Basic Exam #1 Review
A nurse is caring for a client who requires cold application with an ice pack to reduce the pain of an ankle injury. Which action should the nurse take?
Put it on for 30 minutes
A nurse is caring for a client with late stage Alzheimers Dz and is hospitalized with pneumonia. During the nightshift the client is found climbing into the bed of another client. What will you do?
Get the client back to their room
A nurse is preparing a presentation at a senior center about age related musculoskeletal changes. Which of the following changes should the nurse plan to include?
Muscle mass decrease
A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will do more harm than the disease and subject the client to harmful chemical reaction. Which ethical principle does this break?
Non-maleficence
A nurse has access to the facilities electronic client health records. It is appropriate for the charge nurse to share her personal password with who?
Noone
The family of a client demonstrating confusion state "that is not the client's normal behavior" How should the nurse document this?
Objective data
A nurse intercepts a messenger at the nursing station who has a flower delivery for a client on the unit. As the nurse accepts the flowers the messenger says, "I know Mrs. Walsh from the neighborhood". How should the nurse respond?
"It's my responsibility to remind you, that we have to respect our clients privacy"
An older client has become very confused after becoming hospitalized earlier in the week. Prior to this illness the client exhibited clear thought processing and was able to maintain an independent life. What is the client suffering from?
Delirium
A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at the greatest risk for skin breakdown?
An older adult who has a hip fracture and is in buck's traction
A nurse is preparing to perform hand hygiene which of the following actions should the nurse take
Apply 4 to 5 mL of liquid soap to the hands
Home health nurse is assessing an older client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
Area rugs
While conducting a dressing change the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
Assessment
AP reports a clients VS as Tympanic Temp 37.1, Pulse: 92, RR: 18, BP: 98/58. Which fo the following VS should they report?
BP: 98/58 mmHg
A female middle-aged adult tells the nurse that she has tested positive for a mutant BRCA-1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?
Breast Cancer
During orientation with a home care agency the nurse is learning the difference between home health care and community nursing. What should the nurse understand as being the focus for home health care?
Client and/or the family
The clients arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value?
Client is dead
A client has been complaining of pain and even thought the nurse has given the maximum amount of medication as ordered byt the physician. Which action demonstrates the nurses respect for the client?
Call the physician, for more medication
A client on diuretic therapy has a serum Potassium level of 3.4 which food should the nurse encourage the client to choose from the dinner menu?
Cantaloupe
The nurse in a providers office is reviewing the lab results for a client who takes furosemide for HTN. The nurse notes that the clients potassium level is 3.3. The nurse should immediately suspect the possibility of what?
Cardiac Dysrhythmias
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse identify a decrease in which of the following findings as a sign that the patient is being treated correctly
Decreased Heart Rate
A nurse is orienting a newly licensed nurse about documentation of a clients information in the EHR. Which fo the following statements indicates understanding?
Documentation is a communication tool of the interprofessional healthcare team
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
Forgetfulness gradually progressing to disorientation
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect. Select All That Apply.
Increased BP Increased HR Increased Respiratory Rate
A nurse is reviewing information about HIPAA with a newly licensed nurse which of the following statements by the nurse indicates a lack of understanding
Information about a client can be disclosed at any time to a family member
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity (keeping a promise) by doing what of the following?
Keeping an appointment with a client
The nurse suspects that a clients body is attempting to correct an acid-base imbalance. How will this imbalance be corrected?
Kidney regulation is powerfully effective
When completing a community assessment. The community health nurse will take several aspects into account. Which is the first stage of this assessment that the nurse will complete?
Learn about the people in the community
A nurse is caring for an older adult client, that states, "I am afraid that I may fall while walking to the bathroom at night". Which of the following actions should the nurse take?
Leave the bathroom light on
A client is at the end stage of cancer, which type of services should the nurse suggest as being best for the client?
Palliative
A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which should the nurse select?
Peanut butter and Jelly sandwich
A nurse overhears 2 APs from the med-surg unit discussing a hospitalized client while in the cafeteria. Which of the following is a priority nursing action?
Quielty tell the APs this is not appropriate
A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the patient is clumsy. What will the nurse do?
Report findings to a supervisor
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of violating client confidentiality?
Reporting lab findings to a member of the client's family
A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan?
Request a meal without pork
A nurse is serving on a continuous quality improvement committee. That has been assigned to develop a program to reduce the number of medication administration errors after a sentinel event. What are you going to do?
Review the events leading up to each medication administration error
The client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow's Human Needs Theory ast which level should the nurse recognize the client?
Self-Esteem
A nurse is documenting information in a computerized health record. Which of the following actions jeopardizes client confidentiality?
Sharing Passwords
The nurse is caring for a client who has a had a hip fracture that requires surgical repair. Which of the following healthcare professionals is responsible for obtaining informed consent for the client for the surgery?
Surgeon
A nurse on a long term care unit is creating a plan of care for a client who has Alzheimer's Dz. Which of the following interventions should the nurse include in the plan?
Talk client through the task one step at a time
The nurse identifies that a client is experiencing the resistance stage of the General Adaptation Syndrome. What idd the nurse assess to make this clinical decision?
There is a localized swelling and inflammation of the clients leg wound
The nurse is preparing a clients evening dose of respiradone, when the tablet falls on the countertop. Which of the following actions should the nurse take?
Throw it out, waste it
A nurse is planning care for an older adult client who is at a risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain integrity of the client?
Use a transfer device to lift the client up in bed
The nurse reviewing a lab result for a client who has a pressure ulcer. The nurse should identify elevation on which of the following lab values as an indication that the client has an infection?
WBC
A nurse is caring for a client who is dying. The nurse should incorporate the ethical principle of non-maleficence (do no harm) by taking which action?
Withhold a dose of pain medication if the patient has respiratory depression
