Basics of Nursing Practice

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? 1.Moving the client's bedside table closer to the bed. 2.Encouraging the client to take an available sedative. 3.Instructing the client to call the nurse before going to the bathroom. 4.Assisting the client to telephone home to say goodnight to the spouse

3.Instructing the client to call the nurse before going to the bathroom.

The nurse recognizes that a common conflict experienced by the older adult is the conflict between: 1.Youth and old age 2.Retirement and work 3.Independence and dependence 4.Wishing to die and wishing to live

3.Independence and dependence

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? 1.Ambulation 2.Blowing the nose 3.Visiting with children 4.The semi-Fowler's position

2.Blowing the nose

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? 1.Social 2.Physical 3.Materialistic 4.Environmental

1.Social

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1.diminished. 2.normal. 3.full. 4.bounding

3.full

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include: 1.Providing instructions about restraints used during the procedure. 2.Administering a fleet enema 1 hour before the procedure. 3.Encouraging increased intake of clear fluids. 4.Administering morphine 30 minutes before the procedure.

2.Administering a fleet enema 1 hour before the procedure.

The nurse recognizes that what is the reason the faucets on the sinks in a client's room are considered contaminated? 1.They are not in sterile areas. 2.They are touched by dirty hands when turning the water on. 3.There are large numbers of people who use them each day. 4.Water encourages bacterial growth.

2.They are touched by dirty hands when turning the water on.

The nurse recognizes that the mental process most sensitive to deterioration with aging is: 1.Judgment 2.Intelligence 3.Creative thinking 4.Short-term memory

4.Short-term memory

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? 1.Assault is a threat to do bodily harm to another person. 2.It is a legal wrong committed by one person against the property of another. 3.It is a legal wrong committed against the public that is punishable by state law. 4.Assault is the application of force to another person without lawful justification

1.Assault is a threat to do bodily harm to another person.

To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1.Encourage ambulation 2 .Give sips of ginger ale 3.Auscultate bowel sounds 4.Provide a straw for drinking 5.Offer an opioid analgesic

1.Encourage ambulation 3.Auscultate bowel sounds

A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1."Let me get my preceptor." 2."Wash your hands before and after any client care." 3."Clean all instruments and work surfaces with an approved disinfectant." 4."Ensure proper disposal of all items contaminated with blood or body fluids.

2."Wash your hands before and after any client care."

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1.Relieve bronchial spasm. 2.Increase depth of respirations. 3.Loosen pulmonary secretions. 4.Expel carbon dioxide from the lungs

3.Loosen pulmonary secretions

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1.Droplet precautions 2.Reverse isolation 3.Surgical asepsis 4.Medical asepsis

3.Surgical asepsis

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? 1.Kidney dysfunction 2.Cardiovascular diseases 3.Eye problems, such as glaucoma 4.Accidents, including their prevention

4.Accidents, including their prevention

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1.Get a full report from the first nurse and adjust the plan accordingly. 2.Ask the health care provider for a report on the client's condition and plan appropriately. 3.Tell the client about the change in staff responsibilities and assess the client's reaction. 4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

Two nurses are planning to help a client with one-sided weakness to move up in bed. What should the nurses do to conform to a basic principle of body mechanics? 1.Instruct the client to position one arm on each shoulder of the nurses. 2.Direct the client to extend the legs and remain still during the procedure. 3.Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. 4.Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

4.Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

Which nursing activities are examples of primary prevention? Select all that apply. 1.Preventing disabilities 2.Correcting dietary deficiencies 3.Establishing goals for rehabilitation 4.Assisting with immunization programs 5.Facilitating a program about smoking cessation

4.Assisting with immunization programs 5.Facilitating a program about smoking cessation

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? 1.Advising the client to join a support group immediately after discharge. 2.Assuring the family that staff members will take care of the client's needs. 3.Reminding the client to keep medical follow-up appointments after discharge. 4.Conducting a multidisciplinary staff conference early during the client's hospitalization

4.Conducting a multidisciplinary staff conference early during the client's hospitalization

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1.To avoid strain on the incision 2.To promote drainage of the wound 3.To provide stimulation for the client 4.To reduce edema at the operative site

4.To reduce edema at the operative site

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? 1."Effectiveness depends on the child's age." 2."Spanking is strongly suggestive of negative role modeling." 3."Spanking may be the only option when no other technique works." 4."Research studies have shown it to be an effective disciplinary technique."

2."Spanking is strongly suggestive of negative role modeling."

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse? 1."We have no record of that client on our unit. Thank you for calling." 2."The new privacy laws prevent me from providing any client information over the phone." 3."The client has requested that no information be given out. You'll need to call the client directly." 4."It is against the hospital's policy to provide you with any information regarding any of our clients."

1."We have no record of that client on our unit. Thank you for calling."

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past two weeks. The client states "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? 1."You are worried about paying your bills?" 2."Don't worry; your bills will get paid eventually." 3."When was the last time you were admitted for hyperglycemia?" 4."You really shouldn't be drinking alcohol because of your diagnosis of diabetes"

1."You are worried about paying your bills?"

In all states of the United States, what is the professional nurse's legal responsibility regarding child abuse? 1.Honor the request of the parents not to report the suspected abuse. 2.Report any suspected abuse to local law enforcement authorities. 3.Return the child to the legal parent even if he or she is suspected of abuse. 4.Provide the parents with a copy of the child's medical record.

2.Report any suspected abuse to local law enforcement authorities.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? 1.Eggs 2.Yogurt 3.Potatoes 4.Applesauce

2.Yogurt

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? 1.Exempt from any lawsuit because of the doctrine of respondeat superior 2.Totally responsible for the obvious negligence because of failure to report defective equipment 3.Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client 4.Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

3.Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 1.Health care provider, because this decision took precedence over the nurse's concern Incorrect 2.Health care provider, because of total responsibility for the child's health and treatment regimen 3.Nurse, because failure to further question the health care provider about the child's status placed the child at risk 4.Neither, because high fevers are common in children and the health care provider had little cause for concern

3.Nurse, because failure to further question the health care provider about the child's status placed the child at risk

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as: 1. 1+ 2. 2+ 3. 3+ 4. 4+

4. 4+

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1."The body's fluid needs decrease with age because of tissue changes." 2."Access to fluid may be insufficient to meet the daily needs of the older adult." 3."Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4."The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

4."The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? 1.It provides rewards and punishment. 2.The child's development is supported. 3.It reflects the mores of a larger society. 4.It is where child's identity and roles are learned.

4.It is where child's identity and roles are learned

When permitted by the client, the nurse always should take the time to keep the family informed about what is happening to the client. The purpose of this approach is that informed families will be: 1.able to decrease the client's anxiety. 2.more relaxed when interacting with the client. 3.less likely to cause problems with the nursing staff. 4.better equipped to undertake necessary family role changes

4.better equipped to undertake necessary family role changes