Care Management Final Exam Review

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?

Wear a gown when in the client's room

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed."

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 min after eating a meal."

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C & Zinc

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigating solution to 37°C (98.6°F)

A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown.

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound."

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer?

"All of this equipment can be frightening."

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs."

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?

"Can you explain the concerns you're having right now?"

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

"Fats provide energy"

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you."

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery."

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group?

"I think I have done a good job with my children since they are all independent now."

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

"I will put a night-light in the hallway."

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"If I do this often, I won't get pneumonia."

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group?

"We miss our daughter so much that we are going to move closer to her."

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4°C. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

101.1

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560mL

A nurse is teaching the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give to the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

2 tablespoons

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

2 tablets

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2,130mL

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

29 gtt/min

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

30 gtt/min

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

660mL

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

770mL

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse? (Fill in the blank with the numeric value only and round to the nearest whole number.)

8 hours

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the head of the client's bed to 45° before the feeding

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

90mL

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?

A client who has end-stage cirrhosis

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?

Advise the client to perform range-of-motion exercises while in bed

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take?

Advise the client to tuck his chin downward

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?

Antagonistic

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?

Assessment

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client?

Avoid beverages that contain caffeine

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range?

BP 145/90 mmHg

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?

Bounding

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene.

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check capillary refill before applying an ice pack to the affected area

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4 hours

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?

Check the client's vital signs

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform?

Cleanse the wound with 0.9% sodium chloride irrigation

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII (12)

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief?

Denial

A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross?

Depression

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

Ensure the interpreter and the client speak the same dialect.

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning?

Have the client demonstrates the procedure

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client?

Hct 55%

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform?

Hold the linens away from the body and clothing

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability to cry or speak

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response?

Increased blood pressure

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?

Keeping microorganisms from entering the wound

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

Lactose

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher.

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

Locking the brakes on the bed and the wheelchair before moving the client

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter.

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter?

Pace speech to allow time for the interpreter to convey the words.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45-degree angle to the bed.

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?

Potassium 3.0 mEq/L

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

Provide more water with feedings

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent exudate

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

Reduced level of consciousness

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hr

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

Speech-language pathologist

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop the teaching and check with the surgeon about informed consent.

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations?

Tachycardia

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

Test for the presence of the client's gag reflex

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden.

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures.

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?

The signature on the preoperative consent form is the client's.

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.)

Verify the initial X-ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid