Comprehensive workbook questions

A client appears agitated and states, "I'm not sure that I want to go through with this surgery." Which response by the nurse uses the technique of paraphrasing?

"Are you undecided about having this surgery?"

When the nurse is interviewing the wife of a client which statement about the clients husband supports the presence of obstructive sleep apnea? Select all that apply

- he snores and gasps all night long and wakes me up - he has these episodes and never wakes up but i do, and then i cant go back to sleep

A nurse is going to instill medicated drops into the ear of an adult. Which should the nurse do to ensure that the medication flows toward the eardrum?

Press the tragus of the ear several times after insertion

A nurse hangs an IV piggyback of an antibiotic. Within a few minutes, the client reports a thickening of the back of the tongue and swelling under the chin. Place the following interventions in the order in which they should be implemented.

1) turn the IV piggyback 4)Pull the bedside call light out of the wall to initiate an emergency alarm 2) Maintain an airway and administer oxygen 3) instruct a colleague to initiate the rapid response time 5) assign a colleague to hang a new intravenous tubing and an isotonic solution 6) prepare emergency medications according to protocol and await arrival of the members of the rapid response team

A primary health care provider prescribes peak and trough levels for a client receiving an IV antibiotic. What time should the nurse obtain a blood sample to determine a trough level when the antibiotic was administered at 12 noon?

11:30 am

A primary health care provider prescribes the insertion of an indwelling urinary catheter (retention, foley) as part of the client's preoperative prescriptions. Place the following steps of the procedure in the order in which they should be performed by the nurse.

2) Open the catheterization package 1) Don sterile gloves 3) place a fenestrated drape over the client's perineal area 5) Maintain spread of labia while swiping each labium with a separate cotton ball 4) Maintain spread of labia while swiping directly over the urinary meatus

A client prefers and excessively maintains the supine position. For which potential problem associated with this position should the nurse assess the client?

Pressure against the heels

A primary health care provider prescribes diltiazem (Cardizem) 75 mg by mouth three times a day. The scored diltiazem tablets are labeled 30 mg/tablet. How many tables should the nurse administer? Record your answer using one decimal place

2.5 tablets

A nurse is taking a client's temperature using the instrument in the illustration. Place the following steps in the order in which they should be implemented.

4) clean the probe, following the manufacturer's directions 2) position the probe flat on the middle of the forehead, stopping when the hairline on the side of the face is reached 1) while holding the button down and keeping the probe flat against the forehead, slide the instrument across the forehead, stopping when the hairline on the side of the face is reached 3) while continuing to hold the button, touch the probe to the soft area behind the earlobe and below the mastoid 5) Release the button

A primary HCP prescribes 500 mg of an antibiotic to be administered IV piggyback (IVPB) every 6 hours for a client with an infection. The vial dispensed by the hospital pharmacist contains 1 g of the prescribed antibiotic in powder form. The instructions on the vial state, "instill 9.6ml to yield 10 ml." How many ml of the antibiotic should the nurse add to the IVPB bag?

5 ml

A client's vital signs are: apical heart rate - 100 beats per minute, radial heart rate - 84 beats per minute, respirations - 20 beats per minute, blood pressure - 140/84 mm Hg. What is the client's pulse deficit? Record your answer using a whole number

84

At which date and time did the client have a respiratory rate of 15 breaths per minute?

9-9 at 04

Which scenario requires a nurse to complete an incident report? Select all that apply.

A client climbed over raised side rails and fell but was not injured A client did not receive a prescribed medication A nurse fell in the hall and broke an arm

A nurse is delegating an assignment to a nursing assistant. Which client who will benefit the most from soaking the feet for several minutes as part of a bath should the nurse assign to the nursing assistant?

A client who was living in an abandoned care

A client develops diarrhea after receiving several intermittent enteral tube feedings. Which should the nurse consider is the cause of the diarrhea before responding to this situation?

A high osmolarity of the feeding

A client who has a transdermal analgesic patch for cancer experiences breakthrough pain with activity. Which is most important for the nurse to do?

Administer the prescribed shorter-acting opioid

A first aid nurse at a beach is caring for a client who sustained a soft tissue injury of the right shoulder after being hit by a surfboard. Which should the nurse do to limit the stress of both edema and bleeding into tissue?

Apply a cold compress

A nurse is caring for a client who is incontinent of stool. Which action should the nurse implement?

Apply a moisture barrier to the client's perianal area

A nurse identifies that a clients breath has a sweet fruity odor. Which of the following should the nurse do next?

Assess for clinical manifestations of hyperglycemia

A nurse in charge is making assignments for a nursing team. Which intervention should the nurse in charge assign to the registered nurse? Select all that apply.

Assessing the skin of a newly admitted client Assisting a client out of bed for the first time after surgery Explaining how a client should self administer a hypertonic enema

A primary health-care provider writes the prescription "client may shower" for a client receiving home care. When the nurse is preparing the client for the shower, the client reports feeling weak and very dizzy. The nurse determines that the client will not tolerate standing for a shower safely. Which should the nurse do?

Assist the client with a bath while the client is in bed

The nurse is assessing a client who is in pain. Which question should the nurse ask to assess the client's pain tolerance?

At which point on a scale of 0 to 10 do you feel that you must have pain medication?

A client who self-administers an aerosol medication by a metered dose inhaler reports a "nasty taste to the medication." Which should the nurse encourage the client to do?

Attach an aerosol chamber to the metered dose cartridge

A client is using the call bell numerous times an hour and requesting assistance with activities that the client is capable of achieving independently. Which should the nurse do to help this client?

Attempt to see the situation from the client's perspective

A nurse is meeting a client for the first time. Which should the nurse do during the orientation phase of this therapeutic relationship?

Build rapport

An older adult asks the nurse, "i want to make sure I get enough vitamin A to keep my eyes healthy. Which fruits can I eat because I am not fond of vegetables?" Which of the following should the nurse explain is an excellent source of vitamin A? Select all that apply.

Cantaloupe Apricots Peaches Prunes

A nurse must administer a sedative to a client before surgery. Which should the nurse do first?

Check that the surgical consent is signed

A nurse must perform a procedure and is unsure of the exact steps of the procedure. Which should the nurse do first?

Check the nursing policy and procedure manual

A nurse is assessing several clients who had surgery the previous day. Which sudden client response should the nurse identify as a potential infection threatening event?

Chest pain

A nurse is coordinating discharge planning for an older adult who is recovering from a neurological event that left the client with significant right sided weakness. The client and the spouse express concerns about the limitations of their health insurance, the rehabilitation process, and the prescribed low cholesterol, 2 g sodium diet. Which individual should the nurse include in a health-care team conference when planning for this client's discharge needs? Select all that apply.

Client Social worker Registered dietician Home health-care nurse

A nurse identifies a clients perception of health. Which should the nurse do as a result of obtaining this information?

Cluster this data with related data when assessing the client

A primary health care provider prescribes a 2 g sodium diet for a client. Which fluid should the nurse teach is high in sodium? Select all that apply.

Cocoa Low-fat milk Tomato juice

While in a restaurant, a pregnant woman exhibits a total airway obstruction because of a bolus of food. How should the nurse modify the thrusts of the abdominal thrust (Heimlich) maneuver for this woman?

Compress against the middle of the woman's sternum rather than between the umbilicus and xiphoid process

A construction worker comes to the emergency department with an injury that occurred 3 days ago. The client has an open wound of the right calf that has purulent drainage. The medical professional decides to admit the client to the hospital for IV antibiotic therapy and prescribes contact precautions. Which should the nurse in the emergency department do before transporting the client to the room?

Cover the wound with a sterile dressing

A nurse in charge of a surgical unit is reviewing the progress of a variety of clients from the date of surgery to predict the potential date of discharge from the unit. Which of the following should the nurse use to assess the clients progress as a cost containment strategy in managed care?

Critical pathways

A primary health care provider prescribes 1 g of an antibiotic to be administered via the intramuscular route twice a day. The nurse implements all of the following actions. Which nursing action reflects the planning step of the nursing process?

Deciding times when the medication should be given

A client is admitted to the emergency department after sustaining a crushing injury at work. For which characteristic of blood pressure should the nurse assess the client to identify impending shock?

Decreasing systolic

A nurse working in a nursing home routinely administers digoxin 0.125 mg by mouth to a client every morning. Which of the following should alert the nurse to withhold the medication? Select all that apply.

Diplopia Vomiting Bradycardia Dysrhythmias

A nurse arrives on the unit during the last 5 minutes of a 20 minute change of shift report for the second time within a week. How should the nurse in charge handle this situation?

Discuss the lateness with the nurse in private immediately after the report

A nurse is assisting with a bed bath for a client who has moderate cognitive deficits. Which is important for the nurse to do?

Encourage attention to each task of bathing

A nurse is caring for a client who recently received a diagnosis of diabetes. The nurse institutes all of the following interventions. Which nursing action reflects teaching self-management in the affective domain?

Encouraging the client to express feelings about this new medical challenge

A nurse is caring for clients who are on a medical/surgical unit in a a hospital. Which should the nurse do to best prevent clients from falling due to physical hazards?

Ensure adequate lighting

A nurse is administering a lozenge to a client's buccal area of the mouth. Which should the nurse do? Select all that apply.

Ensure the client stays awake while the lozenge dissolves

A nurse transfers a client from a bed to a wheel chair. Which should the nurse do after placing the client in the wheelchair?

Ensure the clients popliteal areas are not touching the seat edge

A nurse in charge is delegating assignments to a registered nurse and a nursing assistant on the nursing team/ which assignment should be delegated to only one registered nurse? Select all that appl.

Evaluating a client's response to activity Taking the pulse of a client with a dysrhythmia Teaching a client how to change a colostomy bag

A newly admitted client arrives on the unit. Which is most important for the nurse to do to help minimize the development of this client's anxiety?

Explain procedures to the client

A nurse is caring for a client who has been having difficulty sleeping. Which should the nurse do because it is the most effective nursing intervention to promote sleep that is appropriate for a client in any situation?

Follow a routine at bedtime

A nurse is caring for a client who is unconscious. Which should the nurse use to best clean this client's oral cavity?

Gauze-wrapped tongue blades with a saline solution

A home health-care nurse is providing care for a client who was discharged from the hospital after receiving acute care for a brain attack (stroke, Cerebrovascular accident) the client has left sided hemiparesis, difficulty swallowing, and anxiety. Which nursing intervention reflects the nurse's role of being a resource person?

Helping the client to negotiate the health-care system within the community

A nurse sees the stable client walking down the hall, as depicted in the photograph. What should the nurse instruct the client to do first?

Hold the urine collection bag below the waist

A nurse is evaluating a nursing assistant changing the linen on an unoccupied bed. Which action by the nursing assistant reflects acceptable medical aseptic technique? Select all that apply.

Holding soiled linen away from touching the nursing assistant's uniform Washing the hands after disposing of a client's linen in a soiled linen hamper

A client with type 2 dm is experiencing blurred vision, generalized weakness, and fatigue. A nurse receives a report from the nurse on the previous shift and obtains additional information from the clients clinical record. Which should the nruse conclude that the client is experiencing?

Hyperglycemic event

A nurse is caring for a client with an infected leg ulcer. Which common systemic response to an infection should the nurse assess for when monitoring this client? Select all that apply.

Hyperthermia Increased heart rate Increased white blood cell count

Which client statement indicates to the nurse that an older adult understands the teaching about how to care for dry skin effectively?

I will increase the amount of water that I drink

Which early response indicates to the nurse that the client is experiencing hypoxia? Select all that apply

Increased heart rate, restlessness, irritability

A nurse is caring for a client who is using an incentive spirometer. Which client behavior observed by the nurse indicates that the teaching was effective? Select all that apply.

Inhales slowly and deeply using the spirometer Raises the inspiratory goal on the spirometer once a day Takes several regular breaths before using the spirometer again

A client's double-lumen nasogastric tube for decompression becomes obstructed. Which should the nurse do?

Instill 10 mL of air into the vent lumen

A nurse is planning a teaching program for a client regarding the learning of a new skill. The nurse assess each of the following. Which factor does the nurse conclude is most relevant when predicting success of the teaching program?

Interest of the client

A nurse is caring for several clients who have different cultural backgrounds and are under stress. Which is an important concept that the nurse must consider when making assessments about these clients nonverbal behavior?

It does not have the same meaning for everyone

A nurse is assessing a client for clinical manifestations of an altered serum potassium level. Which clinical manifestation is common to both hypokalemia and hyperkalemia? Select all that apply.

Muscle weakness Dysrhythmias Nausea

A client who immigrated with her family to the United States 15 years ago is residing in a long term care facility. The nurse sits down next to the client, who is crying. Eventually, the client states, "Our son is 30 years old and still is not married. My husband and I want to arrange a marriage for him, but he refuses. My husband and I have a wonderful marriage, and we had an arranged marriage 35 years ago. Arranged marriages are accepted in our culture. What is the nurse's best response?

It must be troublesome when a son does not agree with your beliefs

Nurses on a unit are personally and professionally mature and motivated. Which one of the following classic leadership styles should the nurse manager employ when working with this group?

Laissez faire

A nurse is caring for a client in the postanesthesia care unit. For which serious complication of intubation associated with the administration of general anesthesia should the nurse assess this client?

Laryngeal spasm

A client states, "I like to have a bowel movement every morning." Which additional information collected by the nurse supports a concern regarding perceived constipation?

Laxatives used excessively

A client has a prescription for a vaginal suppository. Which of the following should the nurse perform when administering this medication? Select all that apply.

Lubricate the suppository and the index finger of a gloved hand before insertion of the suppository Instruct the client to remain flat in bed for 20 min after insertion of the suppository Place the client in the dorsal recumbent position for the procedure

An obese client asks the nurse, "what should I do to help myself lose weight? How should the nurse respond while considereing the best behavior modification strategy for controlling food intake?

Maintain a daily food diary

A nurse causes harm to a hospitalized client because of improper use of a mechanical lift. Based on which specifc tort can this client pursue legal action?

Malpractice

A client has a diagnosis of osteoporosis. Which of the following should the nurse encourage this client to eat? Select all that apply.

Milk Yogurt Sardines Almonds

A client with terminal cancer says to the nurse, "I've been fairly religious, but sometimes I wonder if the things I did were acceptable to God." How should the nurse respond?

Not knowing what the future brings can be an unsettling thought.

A nurse is caring for a client on bed rest. Which client statement should alert the nurse to assess for indications of immobility - induced thrombophlebitis?

One of my calves looks swollen

A nurse is assessing the oxygen status of a dark-skinned client. Where should the nurse assess for cyanosis in this client?

Oral mucous membranes

A client has a temperature of 102 and reports feeling cold. For which additional response should the nurse assess the client during this onset phase (cold or chill phase) of a fever? Select all that apply.

Pale skin Shivering

A nurse is providing dietary teaching for a client who follows a plant-based (pure) vegan diet, which food combination that is a substitute for a complete protein should the nurse include in the dietary teaching? Select all that apply.

Pasta and peas Legumes and rice

A nurse is administering an intramuscular injection at the client's ventrogluteal site. Which action should the nurse implement to help landmark this site?

Place the heel of the hand on the greater trochanter

A nurse is obtaining a client's blood pressure. Which of the following will result in an accurate blood pressure measurement? Select all that apply.

Positioning the arm at the level of the heart Pumping the cuff about 30 mm Hg above the point where the brachial pulse is lost on palpation Releasing the valve on the cuff so that the pressure decreases at the rate of 2 to 3 mm Hg per second Deflating the cuff completely and waiting 2 minutes before reinflating the blood pressure cuff to take the pressure again

A nurse on a postpartum unit is teaching a class for new mothers about umbilical cord care. The nurse identifies that one mother does not become involved with the discussion and is withdrawn. Which is the best action by the nurse to help this new mother learn about umbilical cord care?

Provide informal, individual instruction for the mother about cord care

A client's primary health care provider prescribes antiembolism stockings to be worn when out of bed. Which is an important action about antiembolism stockings that the nurse should teach the client?

Put them on before the legs are in a dependent position

A nurse places a client who had abdominal surgery in the semi-Fowler position. The client states, "I prefer to lie flat when in bed. I feel like I am almost sitting up." Which is an appropriate response by the nurse?

Raising the head of your bed supports your breathing

A nurse is teaching a client with dysphagia how to eat safely. Which should the nurse encourage the client to do? Select all that apply.

Reduce environmental stimuli to a minimum Make sure that the mouth is empty after eating

A nurse is caring for a group of clients in the post anesthesia care unit. Which response by a client in the postanesthesia care unit is the priority concern for the nurse?

Reduced level of consciousness

Which should the nurse teach a client when the primary health care provider prescribes ibuprofen, an NSAID, for pain? Select all that apply.

Remain in an upright position for 15 to 30 minutes after taking the drug Drink 8 oz of water with each dose

A nurse determines that a client's IV infusion has infiltrated. Which should the nurse do next?

Remove the infusion and start it in another site

A nurse is caring for a group of four clients. The client with which clinical manifestation requires immediate attention from the nurse?

Respiratory rate of 25 breaths per minute after resting for 3 minutes following activity

A nurse is caring for a client who has had diarrhea for several weeks. For which common problem associated with prolonged diarrhea should the nurse assess the client?

Skin breakdown

A client is told by the primary health care provider that the client has a metastatic lung cancer and is seriously ill. After the provider leaves the room, the client has a severe episode of coughing and shortness of breath and says, "this is just a cold. Ill be fine once I get over it." How should the nurse respond?

Tell me more about your illness

A nurse is assessing the skin of an older adult. Which condition is of most concern to the nurse?

Tenting of the skin

A nurse going off duty is making rounds with the nurse coming on duty and provides a report about each client in the district. Which information reported by the nurse is the most complete?

The client was given an antiemetic an hour ago and reports resolution of the nausea

A nurse is assessing a client who is experiencing pain. Which statement by the client does the nurse determine reflects the quality of the client's pain?

The pain feels like something is on fire

A nurse is monitoring a client who is receiving an IV infusion because of dehydration. Which client response most specifically indicates that the IV fluid replacement is adequate?

Urinary output of 50 mL/hr

A nurse is teaching a group of clients about correct body mechanics. Which action reflects teaching about the principle, the greater the base of support, the more stable the body? Select all that apply.

Use a cane when you walk Seek assistance when you get out of bed

A nurse must obtain a urine specimen from a client with a urinary retention catheter (foley) and explains the procedure to the client. Which should the nurse do next?

Use a clamp to constrict the tubing slightly below the collection port

A nurse is planning to apply a transdermal patch to a client. Which of the following should the nurse implement? Select all that apply.

Use a different site each time to limit skin irritation and excoriation Shave the area to facilitate adherence of the patch and medication absorption Wear clean gloves to protect one's self from absorbing the medication through the hands

A nurse is giving a client a bed bath. Which should the nurse do to increase circulation?

Wash the extremities with firm strokes toward the heart

A nurse is bathing a client. Which action is associated with medical asepsis? Select all that apply.

Washing from the inner canthus to the outer canthus of the eye Changing the bath water after washing the perineal area Wearing clean gloves when washing the perineum

A client is admitted to the hospital with the diagnosis of diverticulitis. Which is the best question the nurse should ask when obtaining an admission history from this client?

What led up to your coming to the hospital today?