Exam 2 Questions

the nurse assess food different clients. for which client do the findings indicate the client is at risk for heart disease? 1. Color: red Location: face, area of trauma, sacrum, shoulders 2. Color: bluish Location: nail beds, lips, mouth, skin 3. Color: pallor Location: face, conjunctivae, nail beds, palms of hands 4. Color: yellow-orange Location: sclera, mucous membranes, skin

client 2

the registered nurse (RN) is evaluating the statements of a new nurse about wound dressings. which statement made by the new nurse is incorrect? 1. "I should wash my hands with alcohol based antiseptic" 2. "I should use the cotton swab placed on the table" 3. "I should wash my hands before touching the wound" 4. "I should wear gloves before touching the site of injury"

"I should use the cotton swab placed on the table"

for which client would the nurse assess the carotid pulse? (select all that apply) 1. client with cardiac arrest 2. client indicated for Allen test 3. client under physiological shock 4. client with impaired circulation to foot 5. client with impaired circulation to hand

1, 3

which standard is important for the nurse to use in critical thinking? (select all that apply) 1. specific 2. fairness 3. relevant 4. confidence 5. independence

1, 3

the nurse manager asks the nurse. "How would you implement clinical decision-making in a group of clients?" which answer(s) provided by the nurse show(s) effective critical thinking? (select all that apply) 1. "I will avoid involving clients as decision-makers and participants in care" 2. "I will discuss complex cases with other members of the health care team" 3. "I will identify the nursing diagnoses and collaborative problems of each client" 4. "I will consider the time it takes to care for clients whose problems have higher priority" 5. "I will decide to perform activities individually to resolve one client problem at a time"

2, 3, 4

while caring for a female client, the nursing student feels a lump in the client's breast. the nursing student tells the RN, "I think this client has breast cancer." which statements of the RN would be appropriate in accordance with the knowing element of Swanson's theory? (select all that apply) 1. try to comfort the client 2. avoid making assumptions 3. assess the client thoroughly 4. check for other signs of breast cancer 5. try to provide support and care to the client

2, 3, 4

which precaution would the nurse implement for herpes zoster? (select all that apply) 1. airborne 2. contact 3. droplet 4. standard

airborne

which nurse is using complex critical thinking skills when caring for a client? 1. talks to the client to identify reasons for their behavior 2. seeks the assistance of a senior nurse to set up an insulin pump 3. follows the agency's manual to insert a foley catheter in a client 4. acts without involving others and accepts accountability

talks to the client to identify reasons for their behavior

when assessing a client after abdominal surgery, which cue would the nurse use to form a data cluster? 1. the client reports pain with movement 2. the client has pain over the surgical area 3. the client wants to know when he can go home 4. the client rates the pain as 8 on a scale of 1 to 10 5. the client has concerns about caring for the wound

1, 2, 4

which question would the nurse ask the client when obtaining their health history? (select all that apply) 1. "tell me about your food habits" 2. "do you use alcohol or tobacco" 3. "have you sustained any person loss recently?" 4. "have you ever experienced any allergic reactions?" 5. "does any family member have a long-term illness?"

1, 2, 4

when would the nurse observe a client to assess their level of functioning? (select all that apply) 1. during mealtime 2. when talking about pain 3. when preparing medication 4. during the assessment interview 5. when administering insulin injections

1, 3, 5

the nurse is collecting information from a client who has arthritis by posing questions to the client. which questions asked by the nurse are closed-ended questions? (select all that apply) 1. "are you having pain" 2. "tell me how your pain has been" 3. "describe how your spouse is helping you at home" 4. "do you think the medication is helping you get pain relief?" 5. "give me an example of a method that helps you get pain relief at home"

1, 4

which factors enable the nurse to know a client better? (select all that apply) 1. economic constraints 2. continuity of care by the nursing staff 3. fewer nurses in the health care facility 4. collection of data about the client's condition 5. engagement in a caring relationship without assumptions

2, 4, 5

diagnosed with COPD, a 50 yo client's clinical data after treatment is: HR of 100 bpm, BP of 138/82 mm Hg, RR of 32 bpm, tympanic temperature 98.2 F, and an O2 of 80%. which vital sign obtained by the nurse indicates a positive outcome? (select all that apply) 1. radial pulse: 70 bpm 2. temperature: 98.6 F 3. RR: 14 bpm 4. BP 110/70 mm Hg 5. O2: 92%

3, 4, 5

which characteristic of the nurse demonstrates open-mindedness as a part of critical thinking behavior? (select all that apply) 1. bring organized and focused 2. working with cognitive maturity 3. seeking the true meaning of any situation 4. respecting the right of others to have different opinions 5. becoming sensitive to the possibility of personal prejudices

4, 5

which site would the nurse prefer to assess for determining the turgor of an older adult? (select all that apply) 1. back of the neck 2. back of the hand 3. palm of the hand 4. on the sternal area 5. back of the forearm

4, 5

which critical thinking kill demonstrates maturity in the nurse? 1. eagerness to acquire knowledge 2. being tolerant of different views 3. trust in own reasoning processes 4. ability to reflect on own judgements

ability to reflect on own judgements

which step would the nurse take first when preparing a concept map for an assigned client? 1. assess the client and gather information 2. arrange cues into clusters that form patterns 3. identify patterns reflecting the client's problems 4. identify specific nursing diagnoses for the client

arrange cues into clusters that form patterns

a client calls out to all nursing staff members who pass by the door and asks them to get something. how can the nurse best manage this problem while meeting the client's needs? 1. assign one staff member to approach the client regularly and interact with the client 2. close the door to the room so that the client cannot see the staff members as they pass by 3. inform the client that one staff member will come in frequently and check whether the client has any requests 4. arrange for a variety of staff members to take turns going into the room to see whether the client has any requests

assign one staff member to approach the client regularly and interact with the client

for which physical assessment situation would the nurse use an alcohol-based hand sanitizer for hand hygiene? 1. before and after palpating a pulse 2. assessing a client with norovirus 3. if the hand brushed a seeping dressing 4. when the hands have contacted sputum

before and after palpating a pulse

according to the nursing process, which action would ht nurse take after administering pain medication to a postoperative client? 1. administer non pharmacological comfort measures 2. inform the health care provider of the nursing action 3. create a care plan that addresses the client's pain level 4. determine whether the pain medicine relieved the client's pain

determine whether the pain medicine relieved the client's pain

the registered nurse (RN) instructs a nursing student to use knowledge and experience to choose proper strategies when caring for clients. Which critical-thinking skill would the RN be explaining? 1. analysis 2. evaluation 3. explanation 4. interpretation

explanation

the nurse is teaching assistant personnel about ways to prevent the spread of infection. the nurse decides to emphasize the need to break the cycle of infection. which teaching would be priority? 1. hand washing before and after providing client care 2. cleaning all equipment with an approved disinfectant after use 3. wearing personal protective equipment (PPE) when providing client care 4. using medical and surgical septic techniques at all times

hand washing before and after providing client care

when performing an assessment of the client's reproductive system, which finding in the past medical history indicates the client is at risk of cervical cancer? 1. vaginal discharge 2. ovarian dysfunction 3. human papilloma virus infection 4. hematuria and urinary incontinence

human papilloma virus infection

when identifying an inaccurate match between clinical cues and the nursing diagnosis, in which category would the nurse place this diagnostic error? 1. labeling 2. collecting 3. clustering 4. interpreting

interpreting

while providing care for four different clients. the nurse assesses their breathing pattern. which client's assessment findings indicate cheyne-stokes respiration? 1. regular and abnormally slow 2. regular but abnormally rapid 3. irregular, alternating apnea and hyperventilation 4. abnormally shallow for two breaths followed by apnea

irregular, alternating apnea and hyperventilation

which condition would the nurse suspect when a client's respiratory rate increases and the respirations are abnormally deep and regular? 1. hypoventilation 2. biot respiration 3, kussmaul's respiration 4, cheyne-stokes respiration

kussmaul's respiration

when the nurse develops a nursing diagnosis without validating data obtained from the client, within which category would the error fall? 1. labeling 2. collecting 3. clustering 4. interpreting

labeling

which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? 1. insert a urinary catheter 2. intimate droplet precautions 3. move the client to a private room 4. use a high-efficiency particulate air (HEPA) respirator during care

move the client to a private room

the nurse is caring for a surgical client who develops a wound infection during hospitalization. which classification would this infection belong to? 1. primary 2. secondary 3. superinfection 4. nosocomial

nosocomial

while auscultating the heart, a health care provider notices S3 heart sounds in four clients. which client has the highest risk for heart failure? 1. child client 2. pregnant client 3. older adult client 4. young adult client

older adult client

which action would the nurse take first when caring for a postoperative client who reports pain? 1. provide an ice bag 2. administer pain medication as prescribed 3. perform a focused assessment of the client 4. document the client's complaint in the chart

perform a focused assessment of the client

the nurse changed a dressing on a client's wound with vancomycin-resistant enterococci (VRE). which step would the nurse take to ensure proper disposal of the soiled dressing? 1. place the dressing in the bedside trash can 2. place the dressing in a red bag/hazardous materials bag 3. contact environmental services personnel to pick up the dressing 4. transport the dressing to the laboratory to be placed in the incinerator

place the dressing in a red bag/hazardous materials bag

an adolescent client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. which action would the nurse implement? 1. turning on the television for diversion 2. placing the prescribed as-needed warm, wet compress on the elbow 3. calling the primary health care provider for another analgesic prescription 4. informing the client gently that they must wait until the pump reactivates to get more medication

placing the prescribed as-needed warm, wet compress on the elbow

which position would the nurse utilize to asses the client's hip joint extension and buttocks? 1. supine with knees bent 2. prone 3. left lateral recumbent 4. supine

prone

during physical examination, which assessment would the nurse anticipate when a lucent is placed in the lithotomy position? 1. heart 2. rectum 3. female genitalia 4. musculoskeletal system

female genitalia

a client, admitted to the hospital with chest pain, reports shortness of breath, weakness, and vomiting. the nurse suspects cardiac arrest. at which site would the nurse check the client's pulse rate? 1. ulnar 2. radial 3. brachial 4. femoral

femoral

the nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? 1. don an N95 respirator makes before entering the room 2. put on a permeable gown each time before entering the room 3. implement contact precautions and post appropriate signage 4. after finishing with client care, remove the gown first and then remove the gloves

don an N95 respirator makes before entering the room

when obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? (selects all that apply) 1. pain history, including location, intensity, and quality of pain 2. client's purposeful Boyd movement in arranging the papers on the bedside table 3. pain pattern, including precipitating and alleviating factors 4. vital signs, such as increased BP and HR 5. the client's family statement about increases in pain with ambulation

1, 2

which action would the nurse take for a client whose right radial pulse is weak and thready? (select all that apply) 1. assessing all peripheral pulses 2. assessing and comparing both radial pulses 3. asking a second nurse to assess the client's pulses 4. assessing for edema or other issues that may be restricting peripheral blood flow 5. observing for pallor/skin temperature differences distal to the weak pulse

1, 2, 3, 4, 5

which risk factor increases a client's risk for infection in the community? (select all that apply 1. lifestyle 2. occupation 3. chronic disease 4. frequent traveling 5. diagnostic procedures

1, 2, 4

which nursing interventions require the nurse to wear gloves? (select all that apply) 1. giving a back rub 2. cleaning a newborn immediately after delivery 3. emptying a portable wound drainage system 4. interviewing a client in the emergency department 5. obtaining the BP of a client who is positive for human immunodeficiency virus (HIV)

2, 3

while performing a physical assessment of a female client, the nurse positions the client in a left lateral recumbent position. which body system would the nurse assess in this position? (select all that apply) 1. heart 2. vagina 3. rectum 4. female genitalia 5. musculoskeletal system

2, 3

to assess the status of circulation to the foot, which site would the nurse monitor for a pulse? (select all that apply) 1. carotid artery 2. femoral artery 3. popliteal artery 4. dorsalis pedis artery 5. posterior tibial artery

4, 5

which category of isolation would the nurse implement for a client who is positive for Clostridium difficile? 1. airborne precautions 2. droplet precautions 3. contact precautions 4. protective environment

contact precautions

a client with a methicillin-resistant Staphylococcus aureus (MRSA) infected wound is scheduled for a computer tomography (CT) scan. to ensure client and visitor during transport, the nurse would implement which precaution? 1. no special precautions are required 2. cover the infected sire with a dressing 3. drape the client with a covering labeled biohazardous 4. place a surgical mask on the client

cover the infected sire with a dressing

of which cranial nerve does the nurse assess the function when asking the client to shrug their shoulders and to turn their head against passive resistance? 1. cranial nerve II 2. cranial nerve XI 3. cranial nerve VI 4. cranial nerve VII

cranial nerve XI (accessory)

the nurse creates a plan of care for a client with a risk of infection. which is the desirable expected outcome for the client? 1. all nursing functions will be completed by discharge 2. all invasive intravenous lines will remain patent 3. the client will remain awake, alert, and oriented at all times 4. the client will be free of signs and symptoms of infection by discharge

the client will be free of signs and symptoms of infection by discharge

which example demonstrates humility in a critical thinker? 1. the nurse questions the occurrence of pneumonia in a client who has a history of smoking 2. the nurse finds a client in pain and asks specific and detailed questions about the pain to provide pain relief 3. the nurse in a surgical scrub touches a contaminated surface and performs the whole process of surgical scrub again 4. the nurse accepts personal lack of knowledge regarding stem cell transplantation and seeks opportunities for learning

the nurse accepts personal lack of knowledge regarding stem cell transplantation and seeks opportunities for learning

when developing a nursing diagnosis for a client after surgery, the nurse documents the "related to" first-time surgery. which assessment activity enabled the nurse to draw this conclusion? 1. the nurse notes nonverbal; signs of discomfort 2. the nurse observes the client's position in bed 3. the nurse asks the client to explain surgery 4. the nurse asks the client to rate the severity of pain

the nurse asks the client to explain surgery