Comprehensive exam 3

A client is admitted with myasthenia gravi

Ptosis

What assessment finding should the nurse identify in a client with fluid volume excess?

Elevated blood pressure

The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort?

Offer high-protein foods

The nurse is evaluating a client's response to diuretic therapy. Which assessment provides the best measure of the client's fluid volume status?

Intake, output, and daily weight

What clinical problem is a suitable for research utilization in nursing?

The value of calcium channel blockers use over ACE inhibitors

An older client who is admitted with terminal cancer of the liver begins to talk with the nurse about spiritual life after death. Which response by the nurse best assesses the client's spiritual needs?

"I notice you have a Bible"

Which entry in the client's medical record provides the best documentation of client care?

0830- IV fluid rate increased to 100 ml/hour according to protocol.

A female client who is diagnosed with an eating disorder has difficulty translating her pain into words. Which approach should the nurse implement to allow this client greater self-disclosure?

Dance therpay

client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect?

Decreases inflammation and pain

The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate?

Blurred vision

A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress?

Arrest of active phase.

The nurse identifies the nursing diagnosis of, Visual sensory/perceptual alterations related to increased intraocular pressure (IOP) for a client with glaucoma. Which nursing intervention should the nurse include in the plan of care?

Encourage compliance with drug therapy to prevent loss of vision.

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement?

Notify HCP

A nurse gives a client a narcotic for pain and must now leave the unit. To whom should the nurse delegate the task of evaluating the client's response to the pain medication?

Nurse-manager

When conducting an assessment interview with a new client, which question should the nurse use to elicit the most information?

Tell me about you family

An 11-year-old boy with oppositional defiant disorder becomes angry and defiant over the rules of the day treatment mental health program. Which response by the nurse is the most effective way to defuse the situation?

Tell the child to go to the gym to play basketball (redirect)

The nurse is assessing a postpartum client who delivered in the car. Which finding should the nurse identify as the earliest manifestation of a puerperal infection?

Temperature of 100.8° F 24 hours after delivery.

To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.)

Fish Beef Vitamin C Tablets Ibuprofen

In which order should the nurse implement these actions when withdrawing a solution from an ampule?

Flick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle.

The nurse is instructing a mother about the care of her child who has pediculosis capitis. Which information should the nurse provide?

Use a fine-toothed comb or tweezers to remove nits.

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an IOP of 28 mmHg. What information should the nurse ask the client?

Use of prescribed eye drops since last exam by ophthalmologist.

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client

Check residual volume every four hours.

What is the largest contributing factor for the increase in the need for home care?

Clients are more acutely ill when discharged from acute care facilities

The nurse manager is developing a plan to increase the local population's utilization of a new community-based public clinic. Which approach should the nurse utilize to obtain the most impact on developing a collaborative partnership with the community?

Conduct a focus group in community to gather data on culturally significant needs

The nurse is administering a nasogastric tube feeding to a client who is comatose. Which finding requires further action by the nurse?

Gastric residual of 150 ml

During a mass casualty incident involving a 1000 or more victims, which action is the priority for the nurse to implement?

Prioritize care for victims

The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request?

Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients.

A 32-year-old male client is admitted with paranoid schizophrenia. The nurse observes the client walking around the unit muttering to himself and gesturing as if he is having auditory hallucinations. Which action provides the most effective psychotherapeutic management?

Reassure the client that he is safe and should rest.

Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider?

Receives carvedilol (Coreg) for heart failure (HF).

Which information is most important for the nurse to provide parents about long-term care for their child with hydrocephalus and a ventriculoperitoneal (VP) shunt?

Shunt malfunction or infection requires immediate treatment.

Pulse oximetry is being used to monitor a client's oxygen saturation. Which client risk factor(s) should the nurse consider as variable(s) that affect this measurement? (Select all that apply.)

Smoking Jaundice Hypotension Type 1 diabetes mellitus

Which therapeutic response should the nurse identify that best evaluates the use of reminiscence strategies with an older adult?

Stimulate memory through associations

Which client information should the nurse obtain that is indicative of the presence of cholelithiasis?

Upper right abdominal pain that occurs after meals and radiates to the back or right shoulder.

The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care?

Use a bedside cool-mist vaporizer during naps and night time.

A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his lifetime?

Vitamin B12

A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication?

Vomiting

A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide?

Social smiling begins at approximately 2 months of age

A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly debilitated and tells the nurse, Since I haven't been able to go to church, I feel out of touch with God. I pray, but I wonder whether my prayers are heard. Which nursing diagnosis should the nurse include in the client's plan of care?

Spiritual distress

A client with cellulitis is recovering at home after experiencing a severe reaction

A malpractice suit based on lack of reasonable and prudent care

A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway?

A nasopharyngeal tube.

The nurse places a heating pad on the lower leg..

All elements are present to find the nurse liable for damages

The mother of an 8-year-old child with a chronic illness and tracheotomy is rooming-in during this hospitalization. The mother insists on providing all of the child's care and tells the nurse how to care for the child. The nurse should recognize that the mother plays which function when planning this child's care?

An expert in care of the child.

Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to intermittent suction. What assessment should the nurse implement to determine proper placement of the NGT?

Aspirate the tube contents to test the pH.

A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor for the risk of which complication?

Aspiration pneumonia.

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child?

Body surface area

The nurse enters a client's room to complete discharge preps and finds the client in tears. the client states that someone fro the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action?

Continue the client's discharge process

The healthcare provider prescribes digital evacuation of a fecal impaction for an older client who is admitted with a closed head injury after falling out of bed. As a part of the procedure policy, the nurse applies a topical anesthetic gel to the rectum. Which rationale best supports the use of the anesthetic gel?

Decrease risk for bradycardia

A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement?

Document a possible Type I latex allergy.

The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting?

Each pass of the suction catheter should take no longer than five seconds.

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement?

Firmly inform the client that acting out anger is not acceptable.

After attending an inservice for bioterrorism preparedness and staff education, the nurse should identify which findings consistent with a possible anthrax exposure?

Flu-like symptoms, gastrointestinal distress, and papular lesions

which action by the nurse-manager demonstrates an effective leadership style

Fosters positive behavior changes in staff members

The charge nurse assigns one nurse to care for a client with shingles and another nurse to care for a client with HIV/AIDS. Which client goal is addressed by the charge nurse's assignments?

Safe and effective care environment

The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and insulin

Shakiness

When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection?

The anterosuperior iliac spine and the greater trochanter.

The parents of a 5-year-old are concerned because their child showed more outward grief when a pet died than when a sibling died from sudden infant death syndrome (SIDS). What response should the nurse provide?

The child focuses on another connection because the sibling's death is misunderstood

What description encompasses the role in client care management played by nursing informatics?

The input and retrieval of electronic data about a client's medical history

The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy?

Weight gain

on the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism

petechiae of the anterior chest wall

The parents of a 4-month-old infant who is hospitalized tell the nurse that they have to work and cannot stay with the baby except on weekends. Which actions should the nurse-manager implement to address the infant's emotional needs?

Assign the same nurse to care for the child each day.

Which evidence supports the application of healthcare informatics and client care technology?

A new sense of order to a problem that facilitates cost-effective analysis and evaluation of care

A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider?

A rigid, boardlike abdomen.

The nurse is teaching a client with Addison's disease about this new diagnosis. What pathophysiological explanation should the nurse share with the client?

Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex

A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures?

Allow the client to die with dignity and without life-prolonging techniques.

An adolescent female who lost fifty pounds during the past three months is hospitalized. During the admission assessment, the client complains of dry skin, poor skin turgor, hair breakage, brittle nails, and a history of menstrual cycle problems. Which finding is most important for the nurse to obtain additional assessment information?

Amenorhea (anorexia nervosa)

The nurse is assessing a child of Chinese descent who arrives in the clinic with an upper respiratory infection and identifies a 5-inch, circular ecchymoses on the child's forehead and back. What factor should the nurse consider as the most likely cause of this finding?

Cupping to remove colds and coughs

Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply).

Encourage verbal and nonverbal communication Maintain a calm demeanor during all interactions

An infant who is delivered at 32-weeks gestation arrives in the nursery intubated. After the infant is placed under a radiant warmer with prescribed ventilator settings, the nurse applies a cardiorespiratory monitor and pulse oximeter, which indicates an oxygen saturation of 80%. What action should the nurse implement first?

Ensure patency of the endotracheal tube.

Which intervention demonstrates the nurse's accountability in a specific decision-making process?

Evaluating a client's outcomes after implementation of care.

An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at school. What intervention should the nurse implement that is most beneficial for this client?

Explain the consequences for breaking the unit rules

A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset because of the expenses of therapy. What information response should the home health nurse provide as the client's advocate?

Explore options with the regional dialysis center about reducing the cost of home dialysis.

Which components are characteristic of practice context?

Factors and systems that contribute to delivery of nursing care

The nurse identifies a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding?

Failure of the liver to convert ammonia absorbed from the bowel to urea.

The nurse is assessing an adult who displays stagnation,....

Generativity versus stagnation

A female client arrives at the clinic because her boyfriend received the results of a Gram stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she has not had any symptoms and almost did not come to the clinic. What information should the nurse provide the client?

Gonorrhea is often asymptomatic in women because the infection is not visible.

Which change in sleep patterns is most likely to occur in an older adult?

Has a decline in stage 4 sleep

A male client with degenerative arthritis of the knees and hips takes an OTC NSAID for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get sleep, I find that I wake up a number of times during the night." Which info should the nurse obtain first?

How intense does the client rate his pain on a scale of 1-10?

The nurse-manager is planning to study a unit problem that engages the nursing staff in evidence-based practice. What is the sequence of activities that the nurse-manager should use? (Arrange in the order from first on top to last on the bottom.)

Identification Review Implementation Identify and develop

A mother brings her 4-year-old boy to the clinic because he spends his day in constant motion, talks excessively, and is easily distracted from playing with his toys. His preschool teacher is unable to keep him focused in the classroom and suggested he undergo a mental health evaluation. Which nursing diagnosis should the nurse formulate?

Impaired Social Interaction

A male client tells the nurse that he is frequently constipated. Which finding should the nurse identify as a common dietary cause of constipation?

Inadequate intake of dietary fiber and fluids

The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. Which interventions should the nurse include in the teaching plan?

Incorporate favorite foods into the adolescent's diet.

Which infant is at risk for Rh incompatibility?

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.

A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare the dose?

Insulin regular (Humulin R).

What information in a client's history indicates the highest risk factor for hepatitis C?

Intravenous drug abuse

A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4 hours, the nurse determines the client has no drainage from the NGT and has absent bowel sounds. What action should the nurse implement?

Irrigate the NGT with normal saline.

The nurse is caring for a client with diabetic ketoacidosis

Kussmaul respirations

Which FHR finding should the nurse report to the HCP immediately?

Late decelerations

A male client calls the crisis center and tells the nurse that he wants to die and is planning to commit suicide. What means of suicide should the nurse determine is most lethal if in the client's possession?

Loaded gun

During admission to the mental health unit, a female client with bipolar disorder, manic phase, is loud, hyperverbal, hyperactive, and is garishly dressed. Which intervention should the nurse include when planning care for this client?

Maintain an environment that reduces stimulation of the client.

A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action?

Maintain dry perineal dressings

Upon admission, the nurse determines a male client with alcohol withdrawal syndrome is experiencing visual and auditory hallucinations, confusion, dehydration, a swollen tongue, and bruising. Which action should the nurse include in this client's plan of care to ensure physiological stability?

Monitor VS

Which assessment finding should the nurse identify in an adult client with sleep deprivation?

Mood swings and irritability

A client with an open reduction and application of an external fixator for open, comminuted fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by analgesics. The client says the toes are numb and tingling, although they appear pink. What action should the nurse implement?

Notify HCP

Which action should the nurse implement to assess for JVD in a client with HF?

Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

The nurse is caring for a client who is one-day post cardiac catheterization with stent placement. Assessment findings are: blood pressure 90/40, heart rate 45 beats/minute, and oxygen saturation at 95% on oxygen nasal cannula at 2 L/minute. Which task should the nurse delegate to the unlicensed assistive personnel (UAP) at this time?

Obtain urine output for the past 4 hours.

The nurse manager is explaining to a new nurse that the nursing units at the hospital are managed by the nursing staff who control self-scheduling of shift work, implement unit quality improvement program, and participate in unit recruitment-retention programs. What type of management model is the nurse manager describing?

Operational shared governance

At what phase of the therapeutic relationship should the nurse ask a male client about his reasons for seeking medical care and hospitalization?

Orientation phase

Which action should the hospice nurse implement to assist a client maintain self-worth during the end-of-life process?

Plan regular visits with the client throughout the day

The nurse identifies a break in sterile technique as a client is draped for an operative procedure. What action should the nurse implement?

Point out the observation immediately to the surgical team.

Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control?

Powerlessness

The nurse is instructing a client about the use of podofilox (Condylox) for the treatment of genital warts. Which information should the nurse provide?

Redness, peeling, and itching may occur at the site of application.

An older Chinese client refuses to perform the range-of-motion and breathing exercises after a surgical procedure and is hesitant to complete hygienic care and grooming. What cultural factor should the nurse consider that is related to this client's behavior?

Reliance on family members to assist with care.

A mother asks the nurse to explain how using time-out to discipline her 2-year-old child is an effective method. Which rationale should the nurse provide?

Removes a reinforcer that a child is receiving

The nurse is providing care for a 6-year-old boy who has a broken arm and multiple bruises

Report the situation to appropriate authorities

A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals?

Respiratory acidosis.

A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles?

Rest and increased carbohydrate intake

Which principle should the nurse use to delegate client care to an unlicensed assistive personnel (UAP)?

The scope of practice defines which nursing interventions that can be delegated

A client who is taking nitroglycerin for angina is concerned about having headaches after taking more than one tablet. What information should the nurse provide?

This is a common side effect due to the vasodilatory effects of the medication.

The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner cannula. Which solution should the nurse use to remove the debris?

hydrogen peroxide

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity?

Tissue ischemia

Which individual may legally sign an informed consent?

A 16-year-old mother for her newborn

The nurse is obtaining a client's consent for a paracentesis. Which information should the nurse provide to ensure the client understands the purpose of the procedure?

A needle is inserted to remove excessive fluid from the abdominal peritoneal cavity.

A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care?

Apply a pressure-relieving mattress under the client.

The nurse is caring for a client who is scheduled for surgery in 2 hours. The client tells the nurse, "My doctor came by to tell me a lot of stuff that I didn't understand, but I signed the papers for surgery anyway." To fulfill the role of advocate, which action should the nurse implement?

Ask the surgeon to return to clarify questions for the client.

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement?

Assess the client's needs for food, liquids, and rest.

The nurse is reviewing the laboratory results of an older client who is admitted to a medical unit. Which serum chemistry values should the nurse recognize as most commonly affected by the aging process? (Select all that apply.)

Calcium Potassium Sodium

The nurse is explaining dietary management to a client with pregestational diabetes during a prenatal visit. Which client statement indicates that the teaching has been effective?

Diet and insulin needs will change significantly throughout my pregnancy.

The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding an older client with dysphagia. Which action by the UAP requires the nurse's intervention?

Divides solid food items into one inch cube pieces

Which family-centered care concept(s) should the nurse encourage family members to use to promote child growth, development, and independence?

Enabling and empowerment

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis?

Initiate a smoking cessation program.

The nurse is catheterizing a 7-year-old boy who has been admitted to the pediatric unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort?

Insert 5 ml of 2% lidocaine lubricant into the urethra.

The nurse notes a client with decreased alertness is having difficulty managing saliva. What is the priority assessment for the nurse to implement prior to feeding?

Presence of a gag reflex

The nurse is conducting a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are client-centered and written in behavioral terms. The Continuous Quality Improvement (CQI) Committee's expected benchmark is 98% compliance. The sample size is 200 charts, and the results show 180 charts met the benchmark. Which evaluation outcome should the nurse conclude?

The benchmark was not met and an action plan should be developed.

The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR) decelerations. The nurse recognizes that this change in the FHR pattern is due to which pathophysiological incident?

Umbilical cord compression

What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration?

Use of a compression dressing for firm pressure to the site