block one exam one

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

"Client is reporting that her abdominal pain is rated at 8/10."

A client is questioning the need for surgery. The client asks the nurse, "What should I do?" Which answer by the nurse is based on advocacy?

"Tell me why you do not want the surgery."

The nurse is caring for several clients on a telemetry unit. Which client(s) requires the nurse to assess the pulse rate need for 1 full minute? Select all that apply.

A client with a pulse rate of 38 beats/min. A client diagnosed with arrhythmia. A client with a pulse rate of 130 beats/min.

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated?

Active range of motion

Which statement regarding hospice care and the role of a hospice nurse is most accurate?

After the hospice client's death, the nurse assists the family with the bereavement process up to one year.

Which nursing intervention is an example of tertiary preventive care?

Assisting with speech therapy a client with a traumatic brain injury

Which technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

A client has asked that a nurse witness the signing of the client's will. What should the nurse do prior to witnessing this signature? Select all that apply.

Check to see whether state laws allow the nurse to witness this signature. Assess the client's state of mind. Review the client's medical record. Talk to the client about why the client is signing the will now.

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply.

Decreased near vision Increased systolic and diastolic blood pressure Decreased tissue elasticity

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention?

Determine cause

In which order should the nurse instruct the client to follow when inserting vaginal medication?

Empty your bladder just before inserting the medication. Lubricate the applicator tip with water-soluble lubricant. Lie down, bend your knees, and spread your legs. Separate the labia and insert the applicator into the vagina, and insert the medication. Remain recumbent for at least 30 minutes. Wash and store the reusable applicator properly.

A nurse is caring for a client in the community who is at risk for sudden death from a chronic health condition. To reduce the legal risks associated with working with this client, the nurse carries out which action(s)? Select all that apply.

Follow the prescribed plan of care for the client. Explain every nursing intervention in detail. Document nursing actions shortly after completion.

The nurse consistently assesses an adult's blood pressure as 142/94 mm Hg after measuring it several times. Which is indicated by this blood pressure value?

Hypertension stage 2

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?

Inspect the left lower leg for areas of redness.

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What should the nurse manager educate the nurse about regarding the incident report? Select all that apply.

It should provide a clear, concise recording of the situation It should include factual information about the incident.

The nurse is examining the client's skin to determine whether the delivery of oxygenated blood is sufficient. Which body area(s) will the nurse assess for color change? Select all that apply.

Nail beds Tongue Lips

Which national nursing organization serves as a primary source of research data about nursing education, and is the professional organization for nurse educators?

National League for Nursing (NLN)

A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply.

Order at least two pairs of stockings. Launder the stockings at least every three days.

Which actions by the nurse are appropriate when administering a vaginal cream? Select all that apply.

Perform perineal care cleansing from just above the vaginal orifice downward. Keep the plunger applicator fully depressed until removed from the client. Insert the vaginal applicator directing it downward and backward.

The nurse is caring for a client with visual impairment who has been prescribed two different types of eye drops. Which nursing intervention will best assist the client in differentiating between the bottles of drops?

Place a rubber band snugly around one of the bottles

The nurse is caring for a client who developed a urinary tract infection while hospitalized. What intervention(s) will the nurse initiate to care for this health care-associated infection? Select all that apply.

Standard precautions such as gloves and hand hygiene Move client to a private room for safety precautions Transmission-based precautions including proper disinfecting of equipment

An operating room nurse is putting on sterile gloves to assist with client surgery. Which actions are performed correctly in this procedure? Select all that apply.

The nurse opens the outside wrapper by carefully peeling the top layer back. The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply.

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation

A client has been ordered nasal drops, which the nurse will administer. How should the nurse best position the client?

Upright, with head tilted back

A nurse is caring for a client with scabies for which a topical medication has been prescribed. When educating the client on how to use the medication, which should the nurse tell the client regarding the application?

Use gloves to apply.

The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.

Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. Slide the fingers of the ungloved hand between the remaining glove and the wrist. Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene.

For which clients would the nurse be required to use droplet precautions? Select all that apply.

a client with rubella a client with mumps a client with diphtheria prioritization

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?

crackles

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research

Which of the following can a nurse assess by palpation?

temperature, turgor, moisture

The nurse has collected data related to the recent occurrence of several health care-associated infections (HAIs) in the acute care facility. What nursing interventions should be implemented to decrease HAIs? Select all that apply.

wash hands before and after client care encourage clients to receive vaccinations cluster clients with similar conditions select appropriate personal protective equipment (PPE) for all isolation clients

An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply.

"Did you experience dizziness prior to the fall?" "Can you tell what you were doing before you fell?" "Did you have pain in your hip prior to the fall?" "Is it possible you may have tripped over a rug or a cord?"

Which statement made by the nurse would indicate that teaching regarding the absorption of topical medications in the older adult was effective?

"Diminished subcutaneous fat will lead to the rapid absorption of topical medication."

The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask?

"Do you get all of your medications filled at the same pharmacy?"

The nurse is assigned to various clients on a medical unit. Which statement(s) made to a client by the nurse constitutes assault? Select all that apply.

"I am going to insert a catheter in you if you do not get up to go to the bathroom." "Hold still for these stitches; otherwise, I am going to have to hold you down."

The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?

"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."

The nurse has just completed a teaching session with clients on safety precautions to take when applying a transdermal patch. Which statement made by the client indicates that the teaching was effective?

"I will dispose of the patch with adhesive sides sticking together."

What is the most appropriate nursing response when a client with a BMI of 29 expresses concerns of developing hypertension?

"Since weight is one factor that can increase the risk of developing hypertension we will refer you to a nutritionist for weight management."

Which statement regarding the Code of Ethics for Nurses is most accurate?

"The code is an expression of nursing's own understanding of its commitment to society."

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory?

"What are the month, date, and the year of your birth?"

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? Select all that apply.

"What seems to make the pain worse?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" Intensity

Which statement(s) by a nurse to a charge nurse indicates that the nurse requires further training? Select all that apply.

"When I sign the consent form as a witness, I am saying that the person knows all the risks and benefits of the procedure." "I must make sure I give the client all necessary information about the procedure before I have the client sign the consent form." "When a client is having surgery, it is my responsibility to get the consent."

The nurse has administered a glycerin suppository to a client who has not had a bowel movement for several days. One minute after the nurse inserted the suppository, the client told the nurse that she involuntarily expelled the suppository. What is the nurse's best action?

Apply more lubricant to the suppository and reinsert it.

The nurse is evaluating risk factors for a developmentally diverse group of clients. Which client(s) is at risk for safety? Select all that apply.

A toddler allowed to crawl in a house that has not been childproofed An older adult client with a shuffling gait

A client has tested positive for colonization with a multidrug-resistant organism (MDRO) and has been placed on contact precautions. Which actions should be included in this client's care? Select all that apply.

Arrange for the client to be housed in a single room. Use appropriate PPE.

The nurse is caring for a client who has a history of asthma. The client has been admitted to a hospital unit for treatment of shortness of breath related to asthma exacerbation. The client tells the nurse, "I have been using my metered-dose inhalers but I still feel tightness in my chest." Which action(s) will the nurse take in response to the client's statement? Select all that apply.

Assure the client that using inhaled medications can be challenging and provide a demonstration of proper inhaled medication use. Assess the client's SpO2 levels before and after the inhaled medications have been properly administered. Contact the client's provider and recommend the use of a spacer to aid effective administration of inhaled medications. Conduct a thorough review of effective breathing techniques with the client and encourage the client to practice.

The surgical nurse is caring for four clients. Which tasks can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Attaining an admission weight for a client using a portable bed scale. Ambulating the client who is third day postoperative from right knee surgery. Documenting the urinary output of the client with a Foley catheter.

An older client presents to the clinic with reports of dyspnea upon exertion and when lying down as well as feeling tired all the time. The nurse notes that the client's ankles and feet are swollen. What cardiac assessment technique would the nurse use?

Auscultation

The nurse conducts a physical examination of a client who reports moderate to severe abdominal pain. Which data would be important for the nurse to collect during the physical examination?

Bowel sounds

Which components should the nurse include when documenting a critical pathway? Select all that apply.

Care plan Expected outcomes Timeline

While assessing for orthostatic hypotension, the nurse follows which step(s) when taking the blood pressure? Select all that apply.

Check and record blood pressure taken while the client is in the bed. Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. Use the same blood pressure cuff the whole time.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply.

Check that all exit doorways have a STOP sign posted. Place a bell over the client's room and other facility doors.

The nurse is preparing to assess the client's oral temperature using a digital thermometer. Place the steps in the order in which the nurse will perform them. Use all options.

Check the frequency of vital signs assessment in the client record. Review the previous and most recent temperatures recorded. Ask the client if he or she has consumed anything hot or cold within the past 30 minutes. Perform hand hygiene by washing hands or using hand sanitizer. Insert the temperature probe into a disposable cover until it locks into place. Place the covered probe beneath the tongue to the right or left of the frenulum. Maintain the probe in position until an audible sound occurs. Document temperature reading in the client record.

A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply.

Clostridium difficile Norovirus

Which aspect of nursing would most likely be defined by legislation at the state level?

Differences in scope of practice between registered nurses and licensed practical nurses

Which individual provided community-based care and founded public health nursing?

Lillian Wald

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply.

Encourage the client to stand up from a sitting position slowly. Ensure that the client is taking an adequate volume of fluids. Assist the client in applying compression stockings to lower extremities. Ask the client to wait 1 hour after meals to engage in physical activity.

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

Explain rationale for use to the client and family. Pad bony prominences. Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. Ensure that two fingers fit between the restraint and the client's skin. Position limbs in normal anatomic position. Secure restraints to the bed frame with quick-release knots.

A registered nurse checks the American Nurses Association (ANA) regulations prior to delegating tasks to unlicensed assistive personnel (UAP) on a burn unit. Which principles regarding the regulation, education, and use of UAP are recommended by the ANA? Select all that apply.

It is the purpose of assistive personnel to work in a supportive role to the registered nurse. It is the role of the assistive personnel to carry out tasks to enable the professional nurse to concentrate on nursing care for the client. It is the registered nurse who is responsible and accountable for nursing practice.

When preparing medications to provide to a client via enteral tube administration, which nursing action(s) is appropriate? Select all that apply.

Mix powdered drugs with warm water. Finely crush non-enteric-coated medications. Open the shell of capsules to release the powdered drug. Refrain from adding bulk-forming laxatives to the mix.

A new graduate wants to be knowledgeable about state-mandated rules to better practice within the scope of nursing. What are the best resources for this nurse to research? Select all that apply.

Nurse practice acts Nursing educational requirements Composition and disciplinary authority of board of nursing

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply.

Readable Thoughtful Timely Clear, concise, and complete

The older adult client is confused and wanders at night at home. The caregiver is seeking assistance with this problem. The caregiver states, "I am so worried about my family member. What can I do and still get some rest at night?" What instruction(s) would the nurse provide to the caregiver? Select all that apply.

Reduce stimulation, noise, and light a few hours prior to bedtime. Provide low lights in the rooms in which the client may wander. Encourage the client to toilet prior to bedtime. Place locks on any doors to the outside that the client would be able to open.

The nurse is caring for a client that is agitated and combative. What action can the nurse take other than the use of physical restraints? Select all that apply.

Reduce stimulation, noise, and light. Provide a safe environment. Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the designated

The nurse is trying to obtain a temperature and the client continues to bite down on the oral thermometer. The nurse determines a rectal thermometer should be used. What actions demonstrates the nurse's understanding of the client's well-being and safety during this procedure?

Using a digital thermometer, the nurse inserts the covered, lubricated probe 1.5 in (3.75 cm) into the rectum for 1 minute.

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply.

The client exhibits agitation and shouts at the nurse. The client's blood pressure is 135/82 mm Hg. The client's skin turgor is normal. The client has redness around the ankles bilaterally. The client participates in range-of-motion exercises.

The nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing?

SOAP note

Accreditation by which organization is legally required for a school of nursing to exist?

State board of nursing

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?

Temporal artery

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entry(ies) follows the recommended guidelines for communicating and documenting client information? Select all that apply.

The client rates pain as 2 compared to a 7 yesterday. Radial pulse 72 beats/min, strong and regular.

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply.

The client's blood pressure trend over the past 24 hours. The primary reason the client was admitted to the hospital. Objective and subjective data from the most recent assessment. An explanation of what is needed to improve the hypotensive state.

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply.

The client's family must be involved in the decision and care plan. Alternatives to restraints and less restrictive interventions must have been implemented and failed. The benefit gained from using a restraint must outweigh the known risks for that client.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted

A client who has undergone resection of the intestine is NPO with a nasogastric (NG) tube in place. A food tray with regular food comes to the room, and the client insists that the health care provider be called. The nurse insists that it is okay and encourages the client eat the food. The client complies and later develops complications that require another operation. Which action constitutes the primary breach of duty in this situation?

The nurse did not realize the importance and purpose of the NG tube.

The nurse is assessing a client's blood pressure and obtains a falsely low pressure reading. Which nursing actions might have contributed to this false reading? Select all that apply.

The nurse performed the assessment in a noisy environment. The nurse misplaced the bell beyond the direct area of the artery. The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

Which nursing actions will be performed to assist in the prevention of health care-associated infections (HAIs)? Select all that apply.

Wash hands between caring for clients. Recommend vaccinations to clients. Educate clients regarding why antibiotics are not used for viral illnesses.

A nurse is changing the dressings of a client in the burn unit. Which action(s) should the nurse perform to maintain asepsis and client comfort? Select all that apply.

Wash hands thoroughly and then don sterile gloves. Utilize isolation precautions including donning gloves, gowns, and face mask. Ensure family visitors know they cannot bring flowers or fresh fruit to the client. Keep nails short with no polish. Practice good personal hygiene including showering before each shift.

A staff nurse who has been working as a clinical manager is demonstrating strong leadership qualities on the unit. Which behaviors and competencies by the nurse would be recognized by senior management as indicators of strong leadership during evaluation? Select all that apply.

When delegating tasks to unlicensed assistive personnel, the nurse supervises, guides care, and evaluates outcomes. The nurse has achieved certification in the field of professional practice and belongs to that professional practice. The nurse has recognized an error in practice and performance and is managing a task force to change policy.

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur.

Establishing the criteria for the education and licensure of nurses is a component of:

a state's nurse practice act.

Which action(s) by a licensed practical nurse (LPN) will illicit immediate intervention by the registered nurse (RN)? Select all that apply.

administering packed red blood cells to a client with anemia flushing an implanted central venous access device

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?

ask the client to demonstrate self-blood pressure assessment

The nurse is teaching a client about the proper use of transdermal patches. Which location will the nurse teach the client to apply the patch? Select all that apply.

chest abdomen upper arms buttock

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

Following an allergic reaction to a medication, the nurse should:

instruct the client to wear an identification bracelet addressing the allergy.

A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply.

respiratory rate 30/min headache red or flushed skin

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

risk for impaired skin integrity