Davis Advantage Review Questions

The client is being educated about the use of a walker after hip surgery. What directions by the nurse are most important before discharge? Select all that apply. "Do not lean over or pull yourself up with the walker from a sitting position" "Stand between the back two legs of the walker" "Slide the walker forward with each step" "Move your weaker leg forward as you move your walker forward" "Pick up your walker with each step"

"Do not lean over or pull yourself up with the walker from a sitting position" "Stand between the back two legs of the walker" "Move your weaker leg forward as you move your walker forward"

Which of the nurse's questions demonstrates critical thinking? "Have I gathered enough data to make a decision?" "Where do I document my findings?" "When does the nursing intervention need to be performed?" "What assessments must be done?"

"Have I gathered enough data to make a decision?"

Which statements by a nurse are correct when preventing needlesticks and blood exposure? Select all that apply. "I always place my used needles into a puncture-proof, labeled container" "I always recap my used insulin needles before disposing of them" "I confirm that the sharps container is not overfilled before placing the syringe inside" "It is okay to hand pass sharps if both people are wearing gloves" "I use needleless systems when available"

"I always place my used needles into a puncture-proof, labeled container" "I confirm that the sharps container is not overfilled before placing the syringe inside" "I use needleless systems when available"

Which statement by the client indicates emotional distress from immobility? "I'm looking forward to being out of bed" "I don't care if I get cleaned up or not" "I'm getting 6-7 hours of sleep each night" "Theres nothing good on TV"

"I don't care if I get cleaned up or not"

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process? "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal" "Mr. Sullivan will be able to walk the length of the hallway before discharge" "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance" "Ambulate Mr. Sullivan in the hallway three times today please"

"I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal"

Which statement best reflects a critical-thinking philosophy? "Think about different interventions that can be used with this client" "Dig deeper until you reach a single solution" "Don't rely on subjective information, use objective analysis to determine the best protocol" "Trust your gut and go with what you know to be correct"

"Think about different interventions that can be used with this client"

The nurse is providing feedback for a client after several teaching sessions about wound care and dressing changes he will have to perform at home. Which feedback statement would be best? "I can see that you are not retaining the information we discussed. Let's go over it again." "You must remember that when you contaminate, infection can occur." "You did an excellent job washing your hands this time. Let's go over your dressing placement again." "I'll give you a pamphlet to review once you get home."

"You did an excellent job washing your hands this time. Let's go over your dressing placement again."

Steps in order for handwashing:

- Push sleeves above the wrists - Turn on water - Wet hands and all arm surfaces - Apply soap and rub hands together - Clean under finger nails - Rinse hands - Dry hands - Turn off water with paper towel

Which is a safe volume of medication to be administered through the subcutaneous route?

0.5-1 mL

Which specific gravity would the nurse document as normal? 0.12 1.30 1.02 13.0

1.02

Which would be an appropriate technique and preparation for administration of subcutaneous injection in a person who is obese? Select all that apply. 25-27 gauge needle 18-20 gauge needle Inject at 45 degree angle Inject at 90 degree angle Pull skin taut

25-27 gauge needle Inject at 90 degree angle Pull skin taut

Which objective measures can a nurse use to assess a person's dietary history. Select all that apply. Measure body composition Ask about diet 3 day food record diary Food questionnaire 24 hour memory recall

3 day food record diary Food questionnaire 24 hour memory recall

During the administration of a subcutaneous medication, at what angle should the nurse insert the needle?

45 to 90 degrees

A nurse is teaching wellness to a church group. How many daily 8-ounce servings of water should be encouraged for normal bowel health? 4 to 6 servings 6 to 8 servings 8 to 10 servings 10 to 12 servings

6 to 8 servings

Which client would the nurse consider to be at the highest risk of developing a nosocomial infection? A 65 year old client with an indwelling urinary catheter A 30 year old client admitted for dehydration A 45 year old client being treated for GI bleed An 80 year old client admitted with pneumonia

A 65 year old client with an indwelling urinary catheter

The nurse is evaluating clients who may be candidates for patient-controlled analgesia (PCA). In which client would PCA be contraindicated? A 30 year old with fractures from a motor vehicle accident A 45 year old who underwent a total hysterectomy A 60 year old who underwent a total knee replacement A 75 year old with Alzheimers who fell at home

A 75 year old with Alzheimers who fell at home

Which description best explains learning? An interactive process involving planning and implementing instructional activities that meet intended outcomes as well as activities that allow the learner to learn A change in behavior, knowledge, skills, or attitudes to reach common goals A result of motivation to learn that involves planned or spontaneously occurring situations, events, or exposures Using teaching, counseling, and behavioral modification together to achieve effective client learning

A change in behavior, knowledge, skills, or attitudes to reach common goals

A nursing unit is receiving reports for five clients being newly admitted. Which client is at the highest risk for injury and best to place close to the nurse's station? A tearful 9 year old child A depressed 16 year old adolescent An anxious 62 year old A confused 87 year old

A confused 87 year old

Which type of client might be suitable for surgical interruption of a pain pathway? A person who has multiple fractures from a motor vehicle crash An elderly female client with shingles A late stage cancer patient with intractable pain A person who does not have any identified source of pain, but states they are in pain

A late stage cancer patient with intractable pain

The nurse is differentiating between a medical diagnosis and a collaborative problem. Which statements are correct? Select all that apply. A medical diagnosis is managed by nursing interventions A medical diagnosis describes an illness or injury A medical diagnosis identifies pathology A collaborative problem is determined by a medical diagnosis A collaborative problem is managed by both medical and nursing interventions

A medical diagnosis describes an illness or injury A medical diagnosis identifies pathology A collaborative problem is determined by a medical diagnosis A collaborative problem is managed by both medical and nursing interventions

In the communication process, what does the nurse understand the "channel" to be?

A method to send the message

Which is the best example of intellectual courage? A nurse fairly examines their own values and beliefs even when uncomfortable A nurse does not jump to conclusions right away but thinks through all the options before acting A nurse admits they do not have all of the answers and is willing to ask for assistance from others A nurse tries to understand the feelings of other people and visualize a situation from their vantage points

A nurse fairly examines their own values and beliefs even when uncomfortable

How does cognitive impairment affect a person's level of pain?

A person with cognitive impairment may not be able to identify or verbalize being in pain

Nursing documentation should be which of the following? Select all that apply. Accurate Specific Nonjudgemental Opinionated Dispensable

Accurate Specific Nonjudgemental

When determining the right goal, what should the nurse consider? Select all that apply. That the goal is obtainable by the nurse Active learner involvement in planning Agreed-upon mutual goals Realistic objectives Exclusion of the significant other's input

Active learner involvement in planning Agreed-upon mutual goals Realistic objectives

A nurse is assisting a client to a standing position. The client requires frequent breaks and feels short of breath. After standing for a few seconds, the client states exhaustion and needs to lie down again. What should the nurse include in the plan of care?

Activity intolerance

The nurse reassesses the client 30 minutes after administering a narcotic analgesic and notices they have a respiratory rate of 6 breaths/minute. What should be the nurse's first intervention?

Administer a dose of naloxone (Narcan)

The client states, "I don't care if I get better; my father died of heart disease and so will I." Which learning domain needs to be addressed initially?

Affective

A client is admitted to the hospital with bloody sputum and night sweats, signs of tuberculosis. Which precautions must the nurse institute immediately?

Airborne

What are some advantages to computerized safety methods in medication administration?

Alerts for errors, confirms compatibilities, monitors for safe dosing, performs medication calculations

A client has been brought in from a motorcycle accident and suffered deep track-like injuries with debris that can be only partially removed. What type of dressing should be applied to this client's wounds? Alginate Absorbent Antimicrobial Collagen

Alginate

The nurse is providing comfort to a person who has fallen on the hiking trail and broken his ankle. Which techniques can be used until medical help arrives? Select all that apply. Massage Relaxation Meditation Controlled breathing Imagery

All of the above

The nurse is reviewing documentation forms in the facility where she was recently hired. What are some commonly used forms? Select all that apply. Checklists Medication administration records Intake and output records Care plans Kardex

All of the above

The nurse is reviewing the medical record of a client who has not had a bowel movement for 3 days. What factors are concerning? Select all that apply. Client has not eaten for 48 hours. Client is on bedrest. Client is receiving an iron supplement. Client is in a semiprivate room. Client took a laxative prior to hospitalization.

All of the above

What are some common side effects of medications? Select all that apply. Nausea Diarrhea Dizziness Drowsiness Dry mouth

All of the above

What is included in the nurse's ability to make a clinical judgment decision? Select all that apply. Observation and assessment of the presenting situations Identification and prioritization of concerns Generation of evidence based solutions Evaluation of outcomes of solutions Continuous adjustment of care

All of the above

What is the best explanation of teaching? An interactive process involving planning and implementing instructional activities that meet intended outcomes as well as activities that allow the learner to learn A change in behavior, knowledge, skills, or attitudes to reach common goals A result of motivation to learn that involves planned or spontaneously occurring situations, events, or exposures Using teaching, counseling, and behavioral modification together to achieve effective client learning

An interactive process involving planning and implementing instructional activities that meet intended outcomes as well as activities that allow the learner to learn

A nurse is learning about communication concepts and techniques. Which statement by the nurse is correct about intrapersonal communication? An internal dialogue is known as self-talk Communication involves two or more people to accomplish a goal Communication involves more than two people who exchange ideas at the same time A unique form of group communication is when the speaker interacts with others to varying degrees

An internal dialogue is known as self-talk

Which action made by the nurse indicates the use of clinical judgement? Analyzing a client's temperature changes and assessing for signs of infection Filling out food selections on the menu with the client to determine food preferences Ensuring the bed is in a low and locked position, and call light is in reach Asking the patient to verify their name and date of birth prior to medication administration

Analyzing a client's temperature changes and assessing for signs of infection

The diagnosis step of the nursing process includes which activity? Assessing and diagnosing Evaluating goal achievement Performing and documenting nursing actions Analyzing data

Analyzing data

In which ways can surgery or procedures contribute to slowing bowel elimination? Select all that apply. Anesthesia Increased IV fluids Stress Decreased mobility Manipulation of the bowel

Anesthesia Stress Decreased mobility Manipulation of the bowel

The nurse is about to move a client who is large and unsteady from the bed to a chair. Which actions should the nurse take? Select all that apply. Use a narrow base stance of support Apply a belt restraint Get additional help Clear obstacles Place the client in restraints

Apply a belt restraint Get additional help Clear obstacles

How should the nurse deliver the breakfast tray to the bedside of a client in protective isolation?

Apply respirator mask, gown, gloves, then place the tray in the client's room

The nurse is caring for a client who appears to be in a significant amount of pain, thrashing in the bed and moaning. When asked the pain on a 0 to 10 scale, the client says it is a 2. What action should the nurse take next? Ask the client if they would like something for the pain Question if that number is accurate Request the client not be so dramatic Administer pain medication

Ask the client if they would like something for the pain

What actions should the nurse take during the orientation phase of developing a therapeutic relationship with a client? Communicate with active listening Collect pertinent info in a report to provide the most efficient care Prepare the nurse and client for future interactions Ask what name the client would like to be called

Ask what name the client would like to be called

The nurse enters a client's room to obtain a fasting blood glucose reading and notices the breakfast tray is in front of the client. Which action best indicates the nurse using critical thinking? Obtaining blood glucose reading and documenting the client is halfway through breakfast Asking the client if they have eaten any food yet Deferring the blood glucose reading until the next time it is scheduled Notifying the healthcare provider that the client has eaten prior to the blood glucose reading

Asking the client if they have eaten any food yet

What are the steps of the nursing process in order?

Assessment Diagnosis Planning Implementation (Evaluation)

Place the items in the correct order used when documenting the nursing process for a client who is experiencing pain.

Assessment Nursing diagnoses Plan Implementation Evaluation

How does cognitive behavior therapy (CBT) help with pain?

Attempts to alter negative thought patterns

The nurse admits a client with fever and chills. The nurse is concerned the client may have a urinary tract infection, so which other symptoms should the nurse ask about? Select all that apply. Night sweats Back pain Painful urination Bladder spasms Urgency

Back pain Painful urination Bladder spasms Urgency

The client expresses a desire to lose weight. An increase in which of these will best achieve that? BMI Calorie intake Basal metabolic rate Body composition analysis

Basal metabolic rate

In which situation is a topical pain reliever appropriate? Before giving a child an injection Before major surgery Before a colonoscopy As an adjuvant after surgery

Before giving a child an injection

When should the three checks take place?

Before preparing the medication, after preparing the medication, and at the client's bedside

According to Leapfrog Hospital Safety Grade (2019), approximately how many avoidable deaths occur in U.S. hospitals each year?

Between 100,000-200,000

What are the parts of a comprehensive nutritional assessment? Select all that apply. Body composition Physical assessment Laboratory findings Body surface area Dietary history

Body composition Physical assessment Laboratory findings Dietary history

Which chronic conditions impact a client's nutritional needs? Select all that apply. Traumatic injury Alcoholism Degenerative joint disease Bowel inflammation Cognitive function

Bowel inflammation Cognitive function Traumatic injury Alcoholism

The nurse is performing a pain assessment on a pediatric client who is being mechanically ventilated. Which pain scale should the nurse use? Critical Care Pain Observation Tool COMFORT scale Neonatal pain, agitation, sedation scale FACES pain scale

COMFORT pain scale

Which is an advantage of intermittent catheterization over indwelling catheters? Convenience to the client Decreased risk of infection Can be removed immediately and client can void normally Convenient for the nurse

Can be removed immediately and client can void normally

An informatics nurse is training a group of students on the advantages of using an EHR. What could be some supporting reasons? Select all that apply. Can be used by several team members simultaneously Less repetition of data More accurate reporting Less down time Faster

Can be used by several team members simultaneously Less repetition of data More accurate reporting Faster

Which natural supplements can be effectively used for pain management? Select all that apply. Cannabidiol Capsicum Omega-3 Fatty Acids Probiotics St Johns Wort

Cannabidiol Capsicum Omega-3 Fatty Acids Probiotics St Johns Wort

Which metabolic process breaks larger particles into smaller ones and releases energy?

Catabolism

The U.S. Department of Health and Human Services (USDHHS) is working to reduce which healthcare-related infections? Select all that apply. Surgical site infections Multidrug-resistant organisms HIV Ventilator associated pneumonia Community acquired pneumonia Catheter associated UTIs

Catheter associated UTIs Ventilator associated pneumonia Surgical site infections Multidrug-resistant organisms

Undigested food first enters the large intestine through which structure? Duodenum Cecum Rectum Sigmoid colon

Cecum

Which structures of the central nervous system are involved in physical coordination?

Cerebral cortex, cerebellum, basal ganglia

An individual suddenly loses a job and experiences the death of a loved one. The person views this as an opportunity for growth and turns to the church for support. Which characteristic of hardiness does this exemplify?

Challenge

A nurse is preparing oral medications. A client is concerned that the blood pressure pill is a different color than the one taken at home. How should the nurse respond? Return it to the pharmacy, as it is the wrong medication Reassure the client that this is what the doctor has prescribed Check the label and dosage and confirm that the medication and dosage is correct- reassure the client that this is a different manufacturer Ask the client to bring their medications from home and they can take those

Check the label and dosage and confirm that the medication and dosage is correct- reassure the client that this is a different manufacturer

The nurse is caring for a male client who is in a prone position. Which locations are at the highest risk for pressure injury? Cheek and ear Genitalia Heels Sacrum Toes

Cheek and ear Genitalia Toes

Which are sources of discomfort associated with injections? Select all that apply. The needle itself Anxiety of the client Movement of the client Chemical irritation Pressure of the volume of medication in the tissue

Chemical irritation Pressure of the volume of medication in the tissue The needle itself

What is the primary danger when administering oral medications to children?

Choking and aspiration

A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe?

Clean catch

A nurse receives an order to deliver a unit of blood if the client's hemoglobin falls below 7.0 g/dL. The nurse enters the room to obtain consent and the client says, "I choose not to take blood; it's not supported by my religion." The nurse makes a note and does not deliver the blood. Which aspect of critical thinking is this nurse using to guide client care? Client's roles Client's culture Individual differences Multiple and varying concerns

Client's culture

What is the benefit of having a client learn in the psychomotor learning domain? Clients are able to analyze information to create ways to meet their own healthcare needs. Clients tend to value what they have learned and understand and implement skills and changes, thus experiencing both affective and cognitive learning. Clients have a sense of a feeling of accomplishment, which builds autonomy. Clients can remember more factual information.

Clients tend to value what they have learned and understand and implement skills and changes, thus experiencing both affective and cognitive learning.

Which structures are contained within a nephron?

Collecting duct, Bowman's capsule, filtrating tubes

Which are ways health providers use documentation to provide quality care? Select all that apply. Communication tool Continuity of care Provide shift report Communicate with family members Legal record

Communication tool Continuity of care Legal record

The nurse's documentation of a wound states, "Round stasis ulcer on right ankle, no tunneling. Clear serous drainage present. Dry dressing applied." What additional documentation is needed? Select all that apply. Condition of wound bed Color Size Skin around the wound Activity level

Condition of wound bed Color Size Skin around the wound

The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? Select all that apply. Confusion Guarding Poor eye contact Moaning Irritability

Confusion Guarding Moaning Irritability

A nurse is auscultating bowel sounds on a client who has had recent abdominal surgery. The sounds are approximately 1 to 2 per minute in each quadrant. Which condition should the nurse expect?

Constipation

Which is the result of the passage of stool through the colon being slowed?

Constipation

If a written order is confusing or unclear, what action should the nurse take?

Contact the provider for clarification

What term describes drugs with limited medical use and high potential for abuse or addiction?

Controlled substances

Which part of the kidney is made up of millions of functional units called nephrons? Cortex Calyx Medulla Renal pelvis

Cortex

The nurse is teaching a patient about the importance of reducing saturated fats in a cardiac diet. Which oils should the nurse recommend as options? Select all that apply. Palm oil Coconut oil Cottonseed oil Peanut oil Olive oil

Cottonseed oil Peanut oil Olive oil

Which safety instructions should the nurse provide to the client using hot or cold for pain relief? Select all that apply. Cover the heating pad or hot pack with a towel Do not leave on longer than 30 minutes Check skin frequently for color changes related to heat Use moist heat or cold packs Notify the healthcare provider of any damage to the skin from hot or cold packs

Cover the heating pad or hot pack with a towel Check skin frequently for color changes related to heat Notify the healthcare provider of any damage to the skin from hot or cold packs

When checking on a postoperative client, the nurse notices evisceration. What action should the nurse take? Cover the wound with sterile towels or dressings soaked in sterile saline solution. Have the client stay in bed with knees bent to minimize strain on the incision. Notify the surgeon. Prepare the client for surgery.

Cover the wound with sterile towels or dressings soaked in sterile saline solution.

Which are vital components of exemplary patient care? Select all that apply. Critical thinking Problem-solving Clinical reasoning Data collection Decision making

Critical thinking Problem-solving Clinical reasoning Decision making

Which factors impact a person's perception of pain? Select all that apply. Developmental stage Developmental age Location Culture and environment Cognitive impairment

Culture and environment Cognitive impairment Developmental stage Developmental age

What effect occurs when the dosage of medication is administered at a greater rate than it is metabolized and excreted?

Cumulative effect

Which are methods of nonpharmaceutical pain management? Select all that apply. Cutaneous therapy Acupuncture Application of heat and cold Reorientation Instructing the client to think about something else

Cutaneous therapy Acupuncture Application of heat and cold

The nurse is performing the digital removal of stool. Which complication should the nurse monitor for? Bleeding Decreased blood pressure Hypertension Decreased heart rate

Decreased heart rate

The client with a diagnosis of multiple myeloma calls the nurse and reports pain of 9 on a scale of 0 to 10 and requests something for the pain. Which type of pain would the nurse document in the health record?

Deep somatic pain

A client presents to the emergency department with nausea and vomiting for 2 days and has not urinated for the past 8 hours. Which is the most likely cause of lack of urine output?

Dehydration

Which statements represent a measurable outcome? Select all that apply. Provide nonpharmacological measures to minimize need for narcotics Administer prescribed stool softener and laxative at bedtime Demonstrate correct method for checking blood sugar by next visit Will have bowel movement within 12 hours after receiving stool softener and laxative Calls nurse when urge to defecate is felt, does not delay defecation

Demonstrate correct method for checking blood sugar by next visit Will have bowel movement within 12 hours after receiving stool softener and laxative Calls nurse when urge to defecate is felt, does not delay defecation

The nurse is planning for a teaching session with a client who is eager to learn more about managing diabetes. Which combination of teaching approaches will allow for the highest retention? Select all that apply. Provide pamphlets about injections for reading. Verbalize how to give an injection. Demonstrate giving an injection. Show a video on giving an injection. Have the client self-administer an injection.

Demonstrate giving an injection. Show a video on giving an injection. Have the client self-administer an injection. Provide pamphlets about injections for reading.

What is considered a risk factor for developing a urinary tract infection? Diabetes Heart disease Liver failure Hypertension

Diabetes

The nurse is collecting a urinary history for an older adult client admitted to the hospital with renal insufficiency and a urinary tract infection. What should be included in the questioning? Select all that apply. Dietary intake Changes in urinary habits History of urinary infection Frequency of urination Fluid intake

Dietary intake Changes in urinary habits History of urinary infection Frequency of urination Fluid intake

During the administration of a metered-dose inhaler, when should the nurse instruct the client to rinse her mouth?

Directly before the dose is administered and directly after administration for certain medications

A nurse is drawing up a medication through a syringe from a single-use vial. After the prescribed amount is drawn up, there is still approximately 5 mL of solution in the vial. Which action should the nurse take?

Discard the remaining medication

The nurse notices a blood pressure cuff in the client's room with spots of dried blood on it. What should be the nurse's next action?

Disinfect it with a chemical cleaner

Which safety precaution should the nurse take when preparing to administer an injection to a client?

Disposing of the needle immediately in the sharps container

Which characteristics of a drug are part of pharmacokinetics? Select all that apply. Absorption Packaging Dosage Distribution Excretion

Distribution Excretion Absorption

What priority concern should the nurse have for a client who has had a stroke and has left-sided hemiparesis?

Disuse syndrome

While preparing a client's medications, a nurse notices that the client has a penicillin allergy, and the doctor has ordered penicillin. What are the next appropriate actions?

Do not give the medication- contact the provider for clarification

Which elements of documentation can be delegated to unlicensed assistive personnel?

Documentation of vital signs and ADLs

The nurse is documenting the delivery of a medication. Which decision by the nurse is unsafe? Recording the client's response to the medication Documenting all side effects that were experienced Explaining what actions were taken for any adverse reactions experienced Documenting the administration of the medication before delivery

Documenting the administration of the medication before delivery

The nurse is preparing to teach a client about a new blood pressure medication that has been prescribed. What should the nurse consider when determining the Right Content for the teaching session? Select all that apply. Has the client taken this or a similar medication before? What is the client's learning level? Is the environment quiet, free of distractions, and private? Does the client understand the need to take this medication? Is the learner free of pain and anxiety?

Does the client understand the need to take this medication? Has the client taken this or a similar medication before? What is the client's learning level?

Which describes components of implementation in the nursing process? Select all that apply. Doing Deciding Delegating Documenting Caring

Doing Delegating Documenting

Which steps are used when drawing up medication from a vial? Select all that apply. Scrubbing the rubber top with an alcohol pad Inserting air into the vial equal to the amount of solution to be removed Using an ampule snapper to open the vial Purging air from the syringe by holding it downward Drawing the medication slowly from the vial

Drawing the medication slowly from the vial Scrubbing the rubber top with an alcohol pad Inserting air into the vial equal to the amount of solution to be removed

Which factors lead to increased numbers of injuries in children and younger adults related to motor vehicle accidents? Select all that apply. Driver distraction Poor driving patterns Failure to use seatbelts Decreased reaction time Improperly placed car seats

Driver distraction Failure to use seatbelts Improperly placed car seats

The nurse enters the room of a client to perform wound care and administer medications. When should the nurse apply clean gloves? Select all that apply. During medication administration Prior to removing soiled dressings Before applying clean dressings Before treating a new patient After giving the client IV medications

During medication administration Prior to removing soiled dressings Before applying clean dressings Before treating a new patient

What should be considered when using abbreviations in nursing documentation?

Each facility should have a list of approved abbreviations, and those that should not be used

What are the characteristics of therapeutic communication? Select all that apply. Empathy Respect Non-confrontation Genuineness Concreteness Sympathy

Empathy Respect Genuineness Concreteness

Why is the role of teaching clients and families and ensuring their proper education important in healthcare? Select all that apply. Empowers autonomy Allows client/family to perform self care Allows for informed decisions regarding health care Empowers family to make decisions for clients Allows for evaluation of client's cognition and readiness to be discharged

Empowers autonomy Allows client/family to perform self care Allows for informed decisions regarding health care

Which phase of wound healing describes collagen fibers breaking down and remodeling? Hemostasis Inflammation Granulation Epithelialization

Epithelialization

A client says to the nurse, "I hate fat. I wonder why the body has it. It serves no purpose!" Which are functions of body fat that the nurse should explain? Select all that apply. Protection of vital organs Produces blood cells Essential to cell metabolism Enables nerve-impulse transmission Helps eliminate wastes

Essential to cell metabolism Enables nerve-impulse transmission Protection of vital organs

The nurse is about to recap a needle. What considerations should the nurse make? Select all that apply. Do not recap unless absolutely unavoidable One handed technique should be used Place the syringe directly into a puncture proof sharps container Bend or break the needle to prevent a needlestick Exposure to pathogens may occur with a needlestick from capping a used needle

Exposure to pathogens may occur with a needlestick from capping a used needle Do not recap unless absolutely unavoidable One handed technique should be used Place the syringe directly into a puncture proof sharps container

The nurse is cleaning a wound using a wet-to-damp dressing, making sure to clean each new section with a new piece of gauze. What should the nurse be assessing for during the wound cleaning? Select all that apply. Type of tissue present Internal bleeding Exudate Odor Client's thirst level

Exudate Odor Type of tissue present

Which pain scales are used to determine a client's level of pain? Select all that apply. OPQRST-AAA FACES Visual analog scale Numeric rating scale Intensity word scale

FACES Visual analog scale Numeric rating scale

What is the nurse's most important tool when creating a health promotion plan for a client?

Face to face time

An older adult client is thinking about several treatment options for a new diagnosis of cancer. The client's family is strongly encouraging the client to take the most aggressive medications despite the client's hesitation. The nurse is asked to provide an opinion. Which critical-thinking attitude should the nurse present? Independent thinking Fair-mindedness Intellectual empathy Intellectual courage

Fair-mindedness

An older adult who lives alone has fallen and fractured the left hip. The client cannot get to the phone to call for help. The pain worsens as time passes and the client becomes confused waiting for someone to come. What factors are exacerbating the situation? Select all that apply. Fear Helplessness Cognitive impairment Need to be independent Hunger

Fear Helplessness Cognitive impairment

What are primary causes of maceration?

Fever, incontinence

What are considered secondary defenses?

Fever, phagocytosis, inflammation, complement cascade

Which describes a person's ability to carry out activities of daily living (ADLs) without undue fatigue, and with enough energy for leisure pursuits or to respond to emergencies?

Fitness

Which findings in the immobile client are complications related to immobility? Select all that apply. Fluid in the lungs Decreasing appetite Muscle growth Constipation Bladder infection

Fluid in the lungs Decreasing appetite Constipation Bladder infection

The nurse documents: D: The client is wheezing and experiencing some shortness of breath with exertion. A: Delivered 2 puffs of inhaler. R: Wheezing lessened after 5 minutes. Which type of documentation is this an example of?

Focus charting

Which type of assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected?

Focused

The nurse is admitting a client to the hospital who is not fluent in understanding or speaking English. What action should the nurse take?

Follow the policy for using a hospital translator

Which are common disorders that impact bowel function? Select all that apply. Food allergies Diverticulosis Pneumonia Seasonal allergies Food intolerance

Food allergies Diverticulosis Food intolerance

Which are included as part of the U.S. Department of Agriculture (USDA) dietary guidelines? Select all that apply. Food safety Adequate exercise Immunization schedules BMI chart Choosing a nutritious diet

Food safety Adequate exercise Choosing a nutritious diet

A client is given the instructions to avoid eating before bedtime, keep the head of the bed elevated at 30 to 40 degrees, and to avoid fatty foods, chocolate, and smoking. Which impaired digestive function is most likely for this client?

GERD

Which are examples of a direct-care nursing intervention? Select all that apply. Giving a medication Notifying the physician of a change in assessment Obtaining vital signs Giving a bedbath Consulting case management for home oxygen

Giving a medication Obtaining vital signs Giving a bed bath

Which are included in the five rights of teaching? \

Goal, context, time, method

The nurse performs an assessment on a client with joint inflammation, pain with movement, and high levels of uric acid in the blood. What condition should be considered?

Gout

Which are tools for recording assessment data? Select all that apply. Graphic flow sheet Intake and output sheet Client handbook Shift report form Primary survey

Graphic flow sheet Intake and output sheet

What is the single most important way to prevent the spread of infection?

Handwashing

A client is starting to exercise more often and eat healthier, and she has scheduled her first mammogram after the recent diagnosis of her mother's breast cancer. What type of health practice is she engaging in?

Health protection

The nurse is preparing for heat and cold application. Which of the following statements are true? Select all that apply. Heat/cold devices can cause superficial tissue damage Heat/cold devices should never come in direct contact with the skin Heat/cold devices are safe to use for all clients Heat/cold devices should be used intermittently Heat/cold devices should be in place for 30 minutes at a time

Heat/cold devices can cause superficial tissue damage Heat/cold devices should never come in direct contact with the skin Heat/cold devices should be used intermittently

What findings should a nurse expect to see if a client has impaired renal function? Select all that apply. High blood pressure Altered mental status Increased urine production Fluid retention Decreased heart rate

High blood pressure Altered mental status Fluid retention

The nurse is caring for a client with untreated prolonged pain sustained in an automobile accident. Which assessment findings could result from the pain? Select all that apply. Increased urine output Hypertension Fever Nausea and vomiting Pneumonia

Hypertension Fever Nausea and vomiting

The nurse is educating a group of clients about risks for food poisoning. Which statement made by a client indicates understanding? I should not consume raw cookie dough It is fine to eat raw sushi in a restauraunt I sometimes drink milk straight from the cow I can leave food out for 3 hours before consumption

I should not consume raw cookie dough

Which are considered parenteral administration of medication? Select all that apply. IM Intravascular Inhaled Oral suspension Topical application

IM Intravascular

A client presents to the emergency department with severe pain related to a kidney stone. Which is the most rapid and effective route to administer pain medications for quick pain relief?

IV

A nurse is caring for a client who is at high risk for falling. The client is weak and confused. What are actions the nurse can take when caring for this client? Select all that apply. Repeat fall risk assessment every 8 hours Place call light within reach Request a social service consult Identify medications that increase fall risk Restrain the patient to the bed

Identify medications that increase fall risk Repeat fall risk assessment every 8 hours Place call light within reach

Which procedure produces a surgical opening in the abdomen and bypasses the large intestine entirely? Sigmoid colostomy Kock pouch Ileostomy Loop colostomy

Ileostomy

What skin-integrity issue should the nurse assess for when working with a client diagnosed with Alzheimers disease? Impaired cognition can lead to pressure injuries. Alzheimers clients are at a higher risk for falls. Most clients with Alzheimers are older and have xerosis. Impaired cognition may interfere with communication.

Impaired cognition can lead to pressure injuries.

A client has a tendency to develop frequent constipation. Which dietary consideration should the nurse recommend?

Increase fiber intake

Which should be included in client teaching to support normal bowel elimination? Select all that apply. Increase fluid intake. Limit fiber intake. Increase caffeine intake. Increase physical activity. Do not ignore the urge to defecate.

Increase fluid intake. Increase physical activity. Do not ignore the urge to defecate.

Which action is most appropriate for a client experiencing constipation? Select all that apply. Increase intake of milk and cheese Increase intake of bread and pasta Increase intake of fruits and vegetables Increase intake of lean meats Increase intake of beans and legumes

Increase intake of beans and legumes Increase intake of fruits and vegetables

A client with chronic pain is experiencing opioid-induced constipation and has not had a bowel movement for several days. What should the nurse suggest?

Increase oral fluid intake to eight 8oz glasses of water per day

What is the effect of physical activity on normal elimination of the bowels?

Increased physical activity promotes normal defecation patterns

A nurse is working in a healthcare facility with a protocol stipulating that clients with pneumonia should turn, cough, and deep breathe. This nurse is assigned to care for a client admitted with pneumonia but does not encourage the client to cough because the client also has esophageal varices from cirrhosis. Which aspect of critical thinking is this nurse using to guide client care? Client's roles Client's culture Individual differences Multiple and varying concerns

Individual differences

Which of the following best demonstrate nurses' critical-thinking skills? Individualized patient care plans Physician's orders Critical pathways Electronic medical records

Individualized patient care plans

The nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen?

Inflammatory phase

A nurse has concerns that an order written on a client is not appropriate. The provider is contacted, who insists the order is correct. The nurse still has reservations about carrying out the order. What is the appropriate course of action?

Inform the supervisor about concerns regarding the order

What is the term for medication delivered by nebulization?

Inhaled

At which point during hospitalization should discharge planning begin? Initial assessment Focused assessment After the discharge order is written After the special needs assessment

Initial assessment

Which interventions can the nurse include in the plan of care to reduce a client's feeling of isolation related to being on transmission-based precautions? Select all that apply. Allow electronics in the client's room Schedule time to spend with the client Provide books and magazines for the client Permit the client time to sit in the day room Instruct family members on transmission based precautions to allow visits

Instruct family members on transmission based precautions to allow visits Allow electronics in the client's room Schedule time to spend with the client

A nurse with several years of experience in the intensive care unit obtains a new job in the newborn nursery at the healthcare facility. Which critical-thinking attitude would be best for the nurse to employ in this new setting when asking for guidance? Intellectual humility Intellectual empathy Fair-mindedness Intellectual courage

Intellectual humility

The nurse is totaling the intake and output record for the shift. What should be included on the intake record? Select all that apply. Intravenous fluids Hot tea Ice chips Ice cream Oatmeal

Intravenous fluids Hot tea Ice chips Ice cream

A nurse is ambulating a client in the hallway who says, "I feel a little dizzy." The nurse immediately grabs a chair and slides it behind the client, having him sit down. According to Tanner's Model of Clinical Judgment, which reasoning skill is the nurse using after hearing this statement? Analytical reasoning Intuitive reasoning Narrative reasoning Reflection in action

Intuitive reasoning

What skin condition should the nurse monitor in a client who is taking blood pressure medication? Ischemia Inhibited wound healing Hematoma Xerosis

Ischemia

What are disadvantages of charting by exception? Select all that apply. Pertinent info could be omitted It is difficult to capture the skilled judgement of nurses It is cumbersome and time consuming It can lead to errors because nurses may think care has been done when it has not It could result in repeat work

It can lead to errors because nurses may think care has been done when it has not Pertinent info could be omitted It is difficult to capture the skilled judgement of nurses

A client says to the nurse, "I feel so sick and weak, I don't think I'll ever be able to go home." Which response by the nurse is therapeutic?

It sounds like you are frustrated. What do you mean by "sick and weak"?

An overweight college student has been eating more fast food and getting less exercise, due to a limitation of time. Which is the best option that the student can choose in order to motivate both lifestyle and behavioral changes?

Join a group program

The nurse is working with an older adult client and designs a care plan to reduce the risk of infection. Which nursing interventions should the nurse include? Select all that apply. Keep the skin clean and dry Offer foods high in protein Encourage frequent rest periods Provide sources of active immunity Place the client in a semi-private room

Keep the skin clean and dry Offer foods high in protein

Medication errors often occur in healthcare. What are some frequently reported reasons for this?

Lack of knowledge, fatigue, poor handwriting, labeling errors, inadequate staffing

Which are urinary symptoms that may occur as a result of the aging process? Select all that apply. Leakage of urine Decreased frequency of urination Decreased volume of urine Nocturnal frequency of urine Bladder infections

Leakage of urine Nocturnal frequency of urine Bladder infections

What is included in the health promotion assessment? Select all that apply. Nutrition Health screenings Life stress review Blood glucose Lifestyle and risk appraisal

Lifestyle and risk appraisal Nutrition Health screenings Life stress review

When educating a client who is obese and lives a sedentary lifestyle about the benefits of exercise, which common goals can the nurse and client develop together? Self report vigorous physical activity measured by how many times per week Engage in aerobic exercise 3 times a week: 10 mins for one week, 20 mins for 2 weeks, then 30 mins for 3 weeks List diseases that can be reduced, including lowering BP and preventing stroke and heart disease Improve mental health by healthy lifestyle choices and shared decision making Decrease HR from 88 and RR from 28 to WNL within 6 weeks

List diseases that can be reduced, including lowering BP and preventing stroke and heart disease Improve mental health by healthy lifestyle choices and shared decision making Decrease HR from 88 and RR from 28 to WNL within 6 weeks Engage in aerobic exercise 3 times a week: 10 mins for one week, 20 mins for 2 weeks, then 30 mins for 3 weeks

When educating a client, which are important factors to consider regarding the client's ability to learn and retain information? Select all that apply. Literacy level of client Desire and motivation Developmental and physical limitations Barriers to communication Culture and religious practices Family dynamics

Literacy level of client Desire and motivation Developmental and physical limitations Barriers to communication Culture and religious practices

Which organ is the primary site for drug metabolism?

Liver

What is the best way for a nurse to develop clinical judgment skills?

Look for clinical changes and question why

The nurse is speaking with a group of nursing students about the use of heat and ice for pain control. Which situations are best for this modality? Select all that apply. Acute abdominal pain Low back pain with spasticity Activity-induced muscle pain Pain from OB procedures Migraine headache

Low back pain with spasticity Activity-induced muscle pain Pain from OB procedures

Which are functions of water in the body? Select all that apply. Solvent Nutrient Lubricant Carries oxygen Body structure and form

Lubricant Carries oxygen Body structure and form Solvent

The nurse is packing a wound during a wet-to-damp dressing change, avoiding the application of the moist dressing to the surrounding tissue. What complication is being prevented with this technique?

Maceration

What can the nurse do to act as a role model and promote health and wellness to clients? Select all that apply. Maintain a healthy BMI Do not smoke Maintain healthy work/life balance Engage in preventative medicine Practice sensory stimulation for stress relief

Maintain a healthy BMI Do not smoke Maintain healthy work/life balance Engage in preventative medicine

The nurse is caring for a client who is obese and is returning from an abdominal surgery. What action should the nurse take to prevent dehiscence of the wound? Maintain bedrest with the head of the bed elevated at 20° and the knees flexed. Identify the risk for impaired tissue integrity. The wound will heal in a week, as evidenced by a progressive decrease in the size of the wound. Provide client education on wound care.

Maintain bedrest with the head of the bed elevated at 20° and the knees flexed.

What is the significance of using standardized reporting formats? It is required by the Joint Commission it is the policy of most facilities Many serious errors can occur as a result of miscommunication Physicians expect this practice among nurses

Many serious errors can occur as a result of miscommunication

Place the anatomical parts of the digestive system in the appropriate order according to how digestion occurs.

Mastication, stomach, duodenum, ileum, cecum

How should the nurse plan to move a client who is obese and immobile?

Mechanical lift

Two nurses are planning to transfer a client out of bed. Which devices could be used? Select all that apply. Mechanical lift Trapeze bar Transfer belt Scoot sheet Footboard

Mechanical lift Trapeze bar Transfer belt Scoot sheet

Which describes the body breaking down nutrients into chemical energy and then into usable energy?

Metabolism

Which are nutrients that are inorganic elements found in nature?

Minerals

An older adult is admitted to the care center for a skin assessment. What areas should the nurse assess using the Braden Scale for Predicting Pressure Sore Risk? Select all that apply. Fluid status Moisture Activity Friction and shear Sensory perception

Moisture Activity Friction and shear Sensory perception

What describes the production of a fine spray, fog, powder, or mist from a liquid drug?

Nebulization

A nurse is instructing nursing students about incorporating critical thinking into client care. Which attributes should the nurse include during this lesson? Select all that apply. Need to find the truth Openness to other options Use of reasoned thinking Capacity to reflect on situations Ability to delegate tasks Ability to convey important information

Need to find the truth Openness to other options Use of reasoned thinking Capacity to reflect on situations

What are the three classifications of analgesics?

Nonopioids, opioids, adjuvants

Which statements are accurate regarding normal flora? Select all that apply Normal flora can synthesize vitamin K Normal flora aid in the digestive process Normal flora can be removed by handwashing Normal flora is permanently found on the skin Normal flora release B vitamins when they die

Normal flora release B vitamins when they die Normal flora can synthesize vitamin K Normal flora aid in the digestive process

During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this?

Objective

Which development-related safety issue should the nurse include when educating the parents of a 6-month-old infant? Supervision when in the pool Objects being placed in the mouth Unsecured front-facing child car seats Protection from playground related injuries

Objects being placed in the mouth

Which nursing action is part of the evaluation phase when performing wound care for a client? Obtaining wound measurements once a week Irrigating the wound with normal saline Observing the drainage of the fresh wound Discussing goals for wound management with the client

Obtaining wound measurements once a week

Which type of evaluation is performed immediately after an intervention and with each client contact?

Ongoing

A nurse who is obtaining a health history through an interview asks, "What can you tell me about your previous knee replacement surgery?" Which type of question is this?

Open-ended

Which are safety challenges related to medication self-administration in older adults? Select all that apply. Opening medication containers Remembering to take medications Studying labels for correct dosing Asking doctors for medications Thinking medications are not needed

Opening medication containers Remembering to take medications Studying labels for correct dosing

Which is the most prevalent type of degenerative disease that can severely limit a person's ability to perform physical activity?

Osteoarthritis

What describes the duration of intensity of pain a person can endure?

Pain tolerance

What words are used across cultures to describe pain?

Pain, hurt, ache

Which term describes medications that are given through injection into tissues or the bloodstream?

Parenteral administration

The nurse in a long-term care facility is caring for a 70-year-old client who has a history of type 2 diabetes mellitus, hypertension, and Parkinson disease. The client takes antihypertensive medications, insulin, and carbidopa/levodopa. The client has functional incontinence due to a shuffling gait and uses a wheeled walker for ambulation. Which factors place the client at risk for falls? Select all that apply. Insulin injections Parkinson disease Wheeled walker use Functional incontinence Type 2 DM Antihypertensive mediations

Parkinson disease Wheeled walker use Functional incontinence Antihypertensive medications

What term describes the period when the concentration of medicine is highest in the blood?

Peak action

Which intervention in the immobile client's plan of care best helps develop muscle strength?

Perform active ROM each hour

The nurse is teaching a family about phantom pain. Which statement is correct? Phantom pain occurs before an amputation The pain is deadened from the surgery Phantom pain is a psychological condition Phantom pain is real and should be treated as such

Phantom pain is real and should be treated as such

What areas of well-being are the goal of the client in health promotion? Select all that apply. Physical Interpersonal Spiritual Mental Employment

Physical Spiritual Mental

The nurse is at the bedside confirming the "right patient" before the administration of a medication. Which statement or question by the nurse is safest?

Please tell me your first and last names.

How can the nurse best describe the attachment of a muscle to a more stable bone?

Point of origin

The nurse on the medical-surgical unit has noticed a client has edema. What is the nurse's greatest concern? Poor oxygen diffusion to the cells can cause skin breakdown. Wound healing is inhibited. Pressure-related injuries occur due to loss of padding. Diminished tactile sensation occurs.

Poor oxygen diffusion to the cells can cause skin breakdown.

What causes individuals who feel powerless about preventing illness to be less likely to engage in health promotion activities? Poor sense of locus of control (external) No sense of locus of control (effort) Ineptness Coping skills

Poor sense of locus of control (external)

There are four essential phases of a therapeutic relationship. Place these statements in order from first phase to last phase.

Pre-interaction phase Orientation phase Working phase Termination phase

A client has been trying to stop smoking for the past several months. During the assessment, the nurse asks when the client last smoked, to which the client quietly states: "Last night, but not since then." The client then says, "I just had a tough day." In which stage of change is this client?

Preparation

The nurse is preparing to ambulate a client. What is the purpose of applying anti-slip slippers prior to having the client get out of bed?

Prevent falls

Which are goals of nursing care for a client with an indwelling urinary catheter? Select all that apply. Prevent infection. Maintain skin integrity. Prevent the client from ambulating. Keep the catheter in as long as possible. Maintain the free flow of urine.

Prevent infection. Maintain skin integrity. Maintain the free flow of urine.

After visiting a dermatologist and being educated on the risk factors for skin cancer, the client begins to use a higher level of sunscreen as well as wearing a hat at all times when outdoors. What type of prevention is the client practicing?

Primary

The nurse recognizes that a client's respiratory rate has increased from 16 to 24 over the last 2 hours. What action should the nurse take? Record the findings only Prioritize the need for further inquiry Evaluate effectiveness of solutions Generate the best solutions

Prioritize the need for further inquiry

The nurse is assisting a client in the emergency department who needs to use the restroom for a bowel movement. Which option is best? Bedpan Bedside commode Public restroom Private restroom

Private restroom

Which condition in older men can result in impaired flow of urine from the bladder into the urethra? Renal calculi Prostatic hypertrophy Cardiovascular disorders Stroke

Prostatic hypertrophy

What are the goals of infection prevention and control in healthcare? Select all that apply. Protect clients from contagions Lower the cost of healthcare services Incorporate use of PPE Meet professional standards and guidelines Protect employees from contracting infections Prevent infectious diseases from entering the healthcare facility

Protect clients from contagions Lower the cost of healthcare services Meet professional standards and guidelines Protect employees from contracting infections

The nurse is caring for a client with a large leg wound. An increase in which nutrients are most important to repair and maintain the cells?

Proteins

The nurse is providing teaching to a teenager with attention-deficit hyperactivity disorder (ADHD) about a newly diagnosed chronic illness. What should be included in the plan of care? Select all that apply. Provide 10-minute teaching sessions three times a day. Reassess teaching plan and revise as needed. Provide reading material with detailed definition of terms. Provide a quiet environment without distractions. Revisit the previously learned material before proceeding.

Provide 10-minute teaching sessions three times a day. Reassess teaching plan and revise as needed. Provide a quiet environment without distractions. Revisit the previously learned material before proceeding.

The nurse is caring for a client who is being treated for pneumonia and develops clostridium difficile from the antibiotic therapy. The client is placed on contact precautions. What interventions should the nurse perform? Select all that apply. Don a mask prior to entering the client's room Double bag all trash and label it as contaminated Remove PPE after leaving the client's room Provide a disposable BP cuff, thermometer, and stethoscope Assign the client to a negative pressure room with high-efficiency particulate air system

Provide a disposable BP cuff, thermometer, and stethoscope Double bag all trash and label it as contaminated

Which are ways the nurse can promote regular bowel movements? Select all that apply. Provide privacy. Remind the client that constipation could occur if they do not defecate regularly Take a matter-of-fact straightforward approach. Control odors to prevent embarrassment. Accompany the client and provide encouragement while they are attempting defecation.

Provide privacy. Take a matter-of-fact straightforward approach. Control odors to prevent embarrassment.

A client recovering from a traumatic brain injury (TBI) with short-term post-traumatic amnesia and impaired mobility is preparing for discharge. Considering the nature of this client's injury, how should the nurse proceed with discharge education on using a walker and signs of disorientation, confusion, chronic pain, and ataxia? Select all that apply. Provide teaching in brief, frequent learning sessions. Present information slowly. Use repetition. Be satisfied with slower progress. Omit certain components that may be extraneous.

Provide teaching in brief, frequent learning sessions. Present information slowly. Use repetition. Be satisfied with slower progress.

Which nursing action reflects the nurse assisting the client in maintaining belief as a component of caring? Bathing and dressing the client Making eye contact with the client Providing encouragement to a client with a new amputation Listening to the client's feelings about the amputation

Providing encouragement to a client with a new amputation

The nurse educator is preparing a class for new graduate nurses about barriers to therapeutic communication. What should the barriers include? Select all that apply. Asking too many questions Asking why Changing the subject inappropriately Offering advice Providing realistic reassurance Providing false reassurance

Providing false reassurance Asking too many questions Asking why Changing the subject inappropriately Offering advice

What anatomical feature makes women more prone to urinary tract infections than men? Increased width of the pelvic bones Proximity of the urethra to the vagina and anus Larger bladder Decreased length of the ureters

Proximity of the urethra to the vagina and anus

A nurse has demonstrated the proper cleaning and dressing change techniques for a client's wound. The nurse has the client then demonstrate the proper technique and repeat the instructions on when to change the dressing and why. By allowing the client to demonstrate learning, which type of educational learning has been practiced? Cognitive Psychomotor Affective Practical

Psychomotor

Which factor most decreases adverse outcomes in a healthcare facility?

Quality nursing care

What factors determine if a client will develop an infection?

Quantity of organisms, virulence of the organism, ability to survive in the host, host's ability to fight off infection

Which is the most accurate method of verifying correct feeding tube placement when a tube is initially placed?

Radiography

Which are common gastrointestinal symptoms suggestive of food allergy? Select all that apply. Nausea Rash around the anus Excessive gas Intestinal bleeding Severe vomiting

Rash around the anus Excessive gas Intestinal bleeding

A nurse observes an interaction between a client and another healthcare team member. Which observations demonstrate active listening by the team member? Select all that apply. Recognizing nonverbal cues by the client Eliminating intrusions and distractions in the room Using all the senses to interpret verbal messages Seeking clarification of unclear ideas Limiting use of direct eye contact

Recognizing nonverbal cues by the client Eliminating intrusions and distractions in the room Using all the senses to interpret verbal messages Seeking clarification of unclear ideas

A family has just learned that their child has been diagnosed with a chromosomal disorder that will have life-altering effects. What can the nurse do to facilitate support for this family to maintain a healthy environment and deal with lifestyle changes? Recommend a support group for the specific chromosomal disorder Educate the patient on grief and loss Provide printed material on the defect Encourage the family to seek caregiver education

Recommend a support group for the specific chromosomal disorder

A nurse is teaching a client about balanced nutrition. Which reference should the nurse provide for the need for vitamins, minerals, proteins, and total calories? Daily reference intake Recommended daily allowance Adequate intakes Standards

Recommended daily allowance

The nurse is encouraging a client to select a role model for health promotion behavior. Which of the following qualities should the nurse instruct the client to look for in a role model?

Reflects client's background and culture

The nurse is educating the parents of a toddler about medication safety in the home. What should the nurse include in the teaching plan? Select all that apply. Keep old medication on hand for future use Refrain from calling medications "candy" Avoid taking medications in front of children Store all medications in child-resistant containers Transfer all medications into different bottles

Refrain from calling medications "candy" Avoid taking medications in front of children Store all medications in child-resistant containers

The nurse is performing an assessment on a client. What should be included in this process? Ability to pay for hospital stay Who brought the patient to the hospital Level of education Religious and spiritual needs

Religious and spiritual needs

Place the levels of Bloom's taxonomy for higher order thinking skills from lowest to highest.

Remembering Understanding Applying Evaluating

Which actions occur to blood as it moves through the peritubular capillaries? Select all that apply. Removes ammonia from blood Hydrogen ions secreted to help maintain normal blood pH Antidiuretic hormone produced Aldosterone secreted Removes creatinine from the blood

Removes ammonia from blood Hydrogen ions secreted to help maintain normal blood pH Removes creatinine from the blood

Which nursing interventions are important for the home-health nurse to perform to promote safety when caring for older adult clients? Select all that apply. Removing throw rugs Moving electrical cords Changing positions slowly Using visual and hearing aids Taking pain medication prior to movement

Removing throw rugs Moving electrical cords Changing positions slowly Using visual and hearing aids

The nurse is teaching a client to perform a complex dressing change on the foot. After completing the procedure, the nurse says, "That was excellent. We'll do it one more time before discharge tomorrow." The client asks why they need to do it again if it was excellent. How should the nurse reply?

Repetition of a task allows you to retain information better

What is the correct procedure for responding to small fires?

Rescue clients Activate alarm Confine the fire Extinguish the fire

A nurse is assessing a 12-year-old client for an annual physical prior to beginning middle school. Which health behaviors are most appropriate to discuss with the client and parent? Select all that apply. Resisting peer pressure to smoke cigarettes Abstaining from sex Avoiding a sedentary lifestyle Knowing the signs of alcohol abuse Educating on the risk factors and symptoms of heart disease

Resisting peer pressure to smoke cigarettes Abstaining from sex Avoiding a sedentary lifestyle

Which describes restorative effects of drugs?

Returns or maintains the body at optimal health

What are the 5 rights of medication administration?

Right patient Right drug Right dose Right route Right time

Determining a client's level of pain prior to a teaching session would be assessing for which of the five rights of teaching?

Right time

Which is a method of providing a comprehensive communication during a hand-off report?

SBAR

Which are outcomes of effective nursing documentation? Select all that apply. Safe nursing practice Continuity of client care Efficient time management Cost conscious nursing care Effective nurse-client relationships

Safe nursing practice Continuity of client care Efficient time management

The nurse is caring for a client with an epidural catheter for pain control. What are the priorities of care? Select all that apply. Safely administering analgesia Ambulating the client hourly Assessing pain while achieving maximum pain control Removing the catheter within 12 hours to prevent infection Preventing or identifying adverse reactions

Safely administering analgesia Assessing pain while achieving maximum pain control Preventing or identifying adverse reactions

The nurse is transferring a client to bed upon admission. Which position should the nurse place the client in before beginning a physical assessment?

Semi-Fowler's

Which critical-thinking skills will a nurse utilize when reviewing the health record of a new client to prepare a nursing diagnosis? Select all that apply. Visualizing potential solutions to a problem Prioritizing or ranking data as needed Thinking independently with curiosity and perserverance Separating relevant from irrelevant data Documenting assessment findings in the health record

Separating relevant from irrelevant data Visualizing potential solutions to a problem Prioritizing or ranking data as needed

Which criteria must be present for an occurrence to be labeled a never event?

Serious, preventable, measurable

The nurse is leading a small support group for survivors of violence. What group characteristics should the nurse provide? Select all that apply. Shared leadership and responsibility Cohesive climate Mutual trust Vaguely defined purpose Shared set of guidelines for functioning Willingness to change what is not working

Shared set of guidelines for functioning Willingness to change what is not working Shared leadership and responsibility Cohesive climate Mutual trust

The nurse is caring for a client after a large abdominal surgery. He is restless and uncomfortable. Which positioning change could be most beneficial? Select all that apply. Trendelenburg Side-lying Head of bed flat Fetal position Head elevation

Side-lying Head elevation

Which type of bowel diversion allows for control over bowel elimination without the need to wear an appliance? Ileostomy Ascending colon colostomy Transverse colon colostomy Sigmoid colostomy

Sigmoid colostomy

An older adult client begins crying after being informed of her terminal illness. Which intervention by the nurse is best?

Sit quietly with the client while she composes her thoughts

A nurse receives a hand-off report on a client who was told he has stage IV colon cancer an hour before. When the nurse enters the room, the client is crying. What should the nurse do next?

Sit with the client and offer your hand

Which nonverbal behavior best enhances communication?

Sitting down to speak with the patient

What are the types of muscle?

Skeletal, smooth, cardiac

A client informs the healthcare provider of increased fatigue upon return from a camping trip last weekend. What would be important to assess for this client? Skin for bug bites Contact with lead paint Ingestion of raw meats Carbon monoxide exposure

Skin for bug bites

The nurse is performing an assessment of a client's body fat content. Which information would best determine this? Weight Percussion Skinfold measurements Basal metabolic rate

Skinfold measurements

A client has a wound that has been allowed to heal through secondary intention due to excessive loss of tissue. What would be an anticipated assessment finding as the wound begins to heal? Evidence of edema, infection, or foreign matter Small pearl-like or pink areas beginning to appear Epithelial and dermal cells forming new skin Platelets and fibroblasts migrating into the wound

Small pearl-like or pink areas beginning to appear

An instructor asks the student nurse about common reasons for urinary incontinence. How should the student respond? Select all that apply. Sneezing and laughing Overfilled bladder Physical disabilities Bladder infection Kidney stones

Sneezing and laughing Overfilled bladder Physical disabilities

A client with heart disease and hypertension should limit which mineral?

Sodium

If a person makes a conscious decision to bend the elbow, which nervous system is applied?

Somatic nervous system

Which type of organization of health records involves members of each discipline recording their findings in a separate section of the chart?

Source oriented

A teen comes to the emergency department (ER) with ankle pain after a soccer injury. The provider determines that the teen has experienced stretching of a ligament that has caused the ligament to tear. How should the nurse document this finding?

Sprain

The nurse is measuring the depth of a client's wound. What piece of equipment should be used to make this measurement? Sterile ruler Sterile vernier caliper Sterile cotton-tipped applicator Sterile string

Sterile cotton-tipped applicator

A client experiences the sudden death of a loved one, causing financial difficulties. They are admitted for evaluation of chest pain. What should the nurse be aware of regarding stress and health for this client?

Stress, even daily stress, can produce an inability to cope and increase the likelihood of illness

The nurse is planning a health promotion screening for an adolescent. What should be included in the screening?

Stress, mental health, alcohol and drug use

When inserting an indwelling catheter, which level of asepsis is used?

Surgical asepsis or sterile technique

The client has developed kidney and blood infection following a bladder infection from the urinary catheter. How would the nurse describe this infection? Select all that apply. Local Systemic Primary Secondary Healthcare-related

Systemic Secondary Healthcare-related

In what forms can oral medications be delivered?

Tablet, sublingual, liquid, powder, buccal

The nurse is asked to be in a group of colleagues to establish a new family visiting policy for the unit. What type of group is this? Task group Ongoing group Self help group Work related social support group

Task group

Which action best demonstrates assertive communication when reporting a change in the client's status? Recording the change in the EMR Telling the provider "you need to order more BP medication because his numbers are higher" Asking the provider "do you think his BP is a little high today?" Telling the provider, "his BP was up to 180/99 today, would you like to change his medications?"

Telling the provider, "his BP was up to 180/99 today, would you like to change his medications?"

How would a nurse best describe a glomerular filtration rate?

The amount of filtrate formed by the kidneys per minute

Which statements are true about parenteral medications? Select all that apply. The body absorbs the drugs faster and more completely The results are predictable Dosage measuring is accurate The medication lasts longer It is less painful for the client

The body absorbs the drugs faster and more completely The results are predictable Dosage measuring is accurate

Which represents correct documentation of an initial nursing assessment for a client admitted with pneumonia? The client appears short of breath, with wheezing in all lung fields The client is admitted with pneumonia and the nurse will watch for respiratory symptoms Respiratory treatments are given as ordered every 4 hours The client reports improved breathing after breathing treatments given

The client appears short of breath, with wheezing in all lung fields

A client has just been shown when and how to self-administer epinephrine (EpiPen). How can the nurse ensure the client fully understands and can self-inject it when needed? The client can verbally explain why it is important, as well as demonstrate the proper use of the EpiPen. The client verbally explains how to administer epinephrine by pointing to areas of the body that are injection sites. The client demonstrates the movements of self-injection.

The client can verbally explain why it is important, as well as demonstrate the proper use of the EpiPen.

During a pain assessment, the nurse notes that the client's heart rate and blood pressure are elevated. How should the nurse document these findings? The client is experiencing physical indicators of pain The client is experiencing psychological indicators of pain The client is experiencing emotional indicators of pain The client is experiencing somatic indicators of pain

The client is experiencing physical indicators of pain

A nurse obtains a client's vital signs. Their vital signs are normal, but the client states their pain is 8 out of 10. What should the nurse assume about the client's pain?

The client is experiencing severe pain of 8/10

Which things should the nurse consider when delivering pain medication to an older adult client? Select all that apply. The client is likely to be taking multiple medications The client will have differences in medication distribution The client is at a higher risk for falls Dosing should begin with a low dose and be increased slowly IV delivery is preferred

The client is likely to be taking multiple medications The client will have differences in medication distribution The client is at a higher risk for falls Dosing should begin with a low dose and be increased slowly

The student nurse is teaching a client with heart failure about healthy food options. When asked to choose between a hamburger and baked chicken, the client states that eating baked chicken is better than eating a hamburger. In this situation, which element represents feedback?

The client stating that eating baked chicken is better than eating a hamburger

What is the most reliable indicator of pain?

The client's self report

A nurse is caring for a client who had a stroke 2 days ago and cannot speak. The client's spouse is visiting during lunchtime. Who should the nurse communicate with? The client's spouse The client, who is learning to communicate using a white board Neither of them Both of them

The client, who is learning to communicate using a white board

If an error is made in nursing documentation, what should the nurse do?

The entry is noted as being an error, and an addendum with correct info is added

The nurse is writing goals for a client's plan of care. What should be considered?

The goals reflect realistic client changes that the nurse hopes to achieve

The nurse is assessing a client experiencing phantom pain. Where does the client say that that pain originated from?

The limb

The nurse is sitting next to a client having an intense conversation about some traumatic life events the client experienced during military service. The client slides his chair back 12 inches from where they are sitting. What should the nurse consider? The nurse is invading his personal distance and he feels uncomfortable The client needs to stretch out his legs The client wants to terminate the conversation The client needs to change the subject

The nurse is invading his personal distance and he feels uncomfortable

Which is an example of a nurse who is using clinical judgment?

The nurse who identifies abnormal findings, investigates whether the findings are new or old, and adjusts the plan of care accordingly

Which statement is correct about critical thinking and the nursing process? The nursing process is a critical-thinking, problem-solving model When using the nursing process, critical thinking is not needed Everything a nurse does requires critical thinking Nursing process is the only form of critical thinking used in nursing

The nursing process is a critical-thinking, problem-solving model

Which chart entry would be part of SOAP documentation? Select all that apply. The client complains of pain at the incision site Redness and edema is noted at incision site The client was discharged home in stable condition The physician was notified about signs of infection at incision site The physician performed sounds, visiting the client in the morning

The physician was notified about signs of infection at incision site The client complains of pain at the incision site Redness and edema is noted at incision site

The nurse is reviewing the wound culture report of a client with a Stage 3 pressure ulcer. The report says that the bacteria count exceeds 100,000 organisms per gram of tissue. What assumption can the nurse make about the wound? The wound is clean. The wound is clean-contaminated. The wound is contaminated. The wound is infected.

The wound is infected.

What is the primary purpose of swaddling a newborn for the first few weeks of life?

Thermoregulation

A client comes to the emergency department with severe shortness of breath and difficulty breathing. He is restless and anxious. Which response made by the nurse offers reassurance and builds trust? Select all that apply. I'll give you some medication to help with your breathing Would you like your family to stay here with you as I step out? Please try not to think about the breathing This must be a frightening situation for you Tell me more about what you are doing when your breathing is most difficult

This must be a frightening situation for you Tell me more about what you are doing when your breathing is most difficult Would you like your family to stay here with you as I step out?

Verbal communication is a key process for caring for clients. Verbal communication consists of which factors? Select all that apply. Vocabulary Pacing and rhythm Facial expressions Timing and relevance Posture and gait Touch

Timing and relevance Vocabulary Pacing and rhythm

What are the characteristics of a passive communicator?

To avoid conflict and let others take the lead

Which method of opioid delivery provides slow, continuous relief of pain?

Transdermal

Which is the process of nociceptors becoming activated by the perception of mechanical, chemical, and thermal stimuli?

Transduction

Which information should always be included in a report in which a client is transferred from one unit to another? Select all that apply. Client's name, age, dx Last set of vital signs Hx of appendectomy 5 years prior Allergy to penicillin Tubes, lines, or IV therapy

Tubes, lines, or IV therapy Client's name, age, dx Last set of vital signs

A nurse is caring for a client who has a nasogastric tube set to low intermittent suction. There is an order to administer a liquid medication through the tube. Which action should the nurse take after the administration of the medication?

Turn suction off on the NG tube and leave off for 30 minutes

What should the nurse confirm as identifiers?

Two of the three: Name, birthday, medical record number

At what times during the shift should the nurse assess the fifth vital sign? Select all that apply. Upon admission Before and after each potentially painful procedure or treatment With each check of vital signs, if the pain is an actual or potential problem With a change in the patient's condition Immediately after the delivery of pain medication

Upon admission Before and after each potentially painful procedure or treatment With each check of vital signs, if the pain is an actual or potential problem With a change in the patient's condition

Which are interventions used to manage and minimize the symptoms of dry mouth? Select all that apply. Increase salt intake Use hard candy or gum Take frequent sips of water Use lip moisturizer Eat acidic foods

Use hard candy or gum Take frequent sips of water Use lip moisturizer

A client is encouraged to use isotonic muscle strengthening. Which recommendations should the nurse give to achieve this? Flexing and relaxing various muscle groups Use of free weights Applying resistance rubber bands during exercise Dancing to music

Use of free weights

Which description best describes a modified sterile technique? Use of sterile gloves and supplies Use of nonsterile gloves with sterile supplies Use of clean hands and supplies with nonsterile gloves Use of sterile gloves with nonsterile supplies

Use of nonsterile gloves with sterile supplies

The home-health nurse is instructing the family of an older adult client about safety precautions that should be taken in the bathroom. Which information should the nurse provide? Select all that apply. Use raised toilet seats Set up grab bars in the shower Purchase a sturdy shower chair for the client Place a throw rug on the floor to dry wet feet Install a fixed showerhead on the wall for

Use raised toilet seats Set up grab bars in the shower Purchase a sturdy shower chair for the client

A 3-year-old is going to have a myringotomy with tubes in the left ear. Which teaching strategy is most appropriate for this developmental stage?

Using play and placing a bandage on a doll's ear

Which reported behavior by a parent of a 4-month-old infant indicates the need for further teaching? Use of sunscreen prior to going outside Warming formula in the microwave Placing all firearms in a locked gun safe Applying childproof locks on cabinets and drawers

Warming formula in the microwave

In which way is pain positive?

Warns of bodily injury

The nurse is inserting an intravenous catheter into a client. Blood drips down from the venipuncture and lands on the nurse's arm. Which intervention should the nurse perform first? Wash the affected area thoroughly Notify the immediate supervisor Complete injury and incident reports Obtain baseline blood testing for HIV and hepatitis

Wash the affected area

The nurse knows that falls most often occur in hospitals and long-term care facilities during which time frames?

Weekends, nights, holidays

Which is the correct formula for calculating body mass index? Weight in pounds ÷ (height in inches)2 Weight in pounds ÷ (height in meters)2 Weight in kg ÷ (height in meters)2 Weight in kg ÷ (height in inches)2

Weight in kg ÷ (height in meters)squared

In which situation would standard precautions be adequate? Select all that apply. While talking with a client with a moist, productive cough While assisting a client with oral care While ambulating a client after a procedure While inserting an IV catheter When changing a dressing for a client with MRSA

While assisting a client with oral care While ambulating a client after a procedure While inserting an IV catheter

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. Which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply. Whole grain bread Peanut butter Turkey Cheese Refried beans

Whole grain bread Peanut butter Refried beans

The nurse is applying good body mechanics while assisting clients. What is being included? Select all that apply. Wide base of support Head facing down Abdominal muscles tight Shoulders dropped forward Chest high

Wide base of support Abdominal muscles tight Chest high

Which statement about the nursing process is correct? Works alongside an individualized plan of care Results in outcomes designed by the client Is composed of a linear process with unique, distinct steps Includes only care that the nurse will deliver

Works alongside an individualized plan of care

The nurse is performing a skin assessment on an older adult client and notices that there are areas of red, dry, scaly, and cracked skin. The client tells the nurse that it itches. How should the nurse document this finding?

Xerosis

A client is diagnosed with an intestinal infection after traveling to a developing country. The nurse should encourage the intake of which food to optimize the gut's normal flora, creating a healthier environment?

Yogurt

Which factors control growth of microorganisms?

pH, light, oxygen, temperature