exam one study guide / hesi eaq questions

The nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. Which step would the nurse do next after placing the nurse's arms under the client's axillae? • Bending and then straightening their knees • Bending at the waist and then straightening the back • Placing one foot in front of the other and then leaning back • Placing pressure against the client's axillae and then raising their arms

Bending and then straightening their knees

Which client is at a high risk for a rise in blood pressure based on the given data?

Client C

Which step of the problem-solving process would be most important for the nurse to consider when addressing a recent increase in client falls on the unit? • Collecting recent data concerning the falls to clearly identify the problem • Analyzing data collected to identify solutions to address issues contributing to falls • Identifying risks and consequences of possible solutions to decrease falls on the unit • Considering how one's own beliefs concerning causes of the recent increase may affect solutions

Collecting recent data concerning the falls to clearly identify the problem

When learning about the rules of leaders, which action of the nurse indicates effective implementation of the rules? Select all that apply. One, some, or all responses. may be correct. •Communicating in a simple language with followers •Giving an opportunity to the followers to express their views •Instructing followers to decide the actions to be performed •Avoiding communicating clear boundaries with followers •Ensuring proper eye contact while communicating with followers

Communicating in a simple language with followers Giving an opportunity to the followers to express their views Ensuring proper eye contact while communicating with followers

Which finding would indicate a need to refer a client to a health care provider when the nurse is screening clients for hypertension? • Report of pain as the blood pressure cuff is inflated • Systolic blood pressure result higher than 120 mm Hg • Diastolic blood pressure reading greater than 89 mm Hg • Loud Korotkoff sounds as the blood pressure cuff is deflated

Diastolic blood pressure reading greater than 89 mm Hg

Which action would the nurse take to decrease abdominal distention after a client's surgery? • Encourage ambulation. • Give sips of ginger ale. • Provide a straw for drinking • Offer an opioid analgesic.

Encourage ambulation.

Which musculoskeletal changes directly place pregnant clients at increased risk for falls? Select all that apply. One, some, or all responses may be correct. •Back pain •Joint laxity •Weight gain •Impaired balance •Shifting center of gravity

Joint laxity Impaired balance Shifting center of gravity

Which topic will the nurse include when educating the parents of an adolescent on home safety? •Nutrition needs •Monitoring of schoolwork •Limiting video game time •Keeping firearms locked away

Keeping firearms locked away

Which intrinsic factor may contribute to falls in older adults? Select all that apply. One, some, or all responses may be correct. •Lack of exercise •Impaired vision •Inappropriate footwear •Improper use of assistive devices •Unfamiliar environment of hospital room

Lack of exercise Impaired vision

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand would the nurse teach the client to hold the cane? •Left hand •Right hand •Stronger hand •Dominant hand

Left hand

Which rationale would the nurse use to explain the cane's purpose to a client with hemiparesis who voices a reluctance to use a cane? • Maintain balance to improve stability • Relieve pressure on weight-bearing joints • Prevent further injury to weakened muscles • Aid in controlling involuntary muscle movements

Maintain balance to improve stability

Which assessment item needs to be documented on a client with restraints? Select all that apply. One, some, or all responses may be correct. •Pulse near the restrained area •Temperature of the restrained area •Convenience of restraining the client •Skin integrity surrounding the restraint •Behavior leading to the need for restraint

Pulse near the restrained area Temperature of the restrained area Skin integrity surrounding the restraint Behavior leading to the need for restraint

Which physiological factor helps maintain blood pressure in the client with hypovolemia? Select all that apply. One, some, or all responses may be correct. •Arteriolar dilation •Release of aldosterone •Activation of angiotensin Il •Sympathetic nervous system activation •Stimulation of the vagus nerve

Release of aldosterone Activation of angiotensin Il Sympathetic nervous system activation

Which initial action would the nurse take when a client reports smoke coming from a utility room on the nursing unit? • Pull the fire alarm on the unit. • Remove anyone who is in immediate danger. • Obtain a fire extinguisher and report to the fire area. • Close all windows and fire doors and await further instructions.

Remove anyone who is in immediate danger.

Which initial action would the nurse take when a client reports smoke coming from a utility room on the nursing unit? •Pull the fire alarm on the unit. •Remove anyone who is in immediate danger. •Obtain a fire extinguisher and report to the fire area. •Close all windows and fire doors and await further instructions.

Remove anyone who is in immediate danger.

Which instruction by the nurse is correct for a client with a fractured leg? •Double the intake of vitamin C. •Remove loose rugs from the environment. •Avoid taking showers until the cast is removed. •Increase weight bearing on the injured leg gradually.

Remove loose rugs from the environment.

A client in traction reports feeling uncomfortable from being in the same position. Which nursing intervention is correct in this situation? • Repositioning the client • Offering basic hygiene measures • Assisting the client with the meal • Providing health teaching to the client

Repositioning the client

The nurse is assisting a client to transfer from the bed to a chair. Which would the nurse do to widen the base of support during the transfer? • Spread the feet away from each other. • Move the client on the count of three. • Tighten the core muscles. • Stand close to the client when assisting with the move.

Spread the feet away from each other.

The nurse prepares to assess a client's heart during a routine health checkup. In which position would the nurse place the client to assess murmurs of the heart?

The client should lie in the lateral recumbent position so the nurse may effectively detect heart murmurs. The supine position provides easy access to the pulse sites. The client should be placed in the dorsal recumbent position for abdominal assessment. Modified left lateral recumbent position is used so the nurse may assess the rectum and vagina.

The nurse is reviewing the procedure for intervention if a fire occurs. Which interventions would the nurse include in the procedure if a fire occurs that relate to the acronym RACE? Select all that apply. One, some, or all responses may be correct. •Activate the alarm. •Alert the local fire department. •Remove all clients from the area. •Evaluate all interventions provided. •Release the pin in the fire extinguisher. •Confine the fire by closing doors and windows.

Activate the alarm. Remove all clients from the area. Confine the fire by closing doors and windows.

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? Select all that apply. One, some, or all responses may be correct. •Area rugs on the floor •Clogged, dirty fireplace •Multiple electrical cords •Multiple prescribed medications •Wheeled walker with uneven legs

Area rugs on the floor Clogged, dirty fireplace Multiple electrical cords Multiple prescribed medications Wheeled walker with uneven legs

Which nursing interventions are beneficial in the event of fire in the hospital? Select all that apply. One, some, or all responses may be correct. •Opening the doors and windows •Moving ambulatory clients in wheelchairs to a safe location •Putting out the fire first and then removing the clients from fire area •Asking ambulatory clients to help push wheelchair clients out of danger •Maintaining injured clients' respiratory status manually until removed from the fire area

Asking ambulatory clients to help push wheelchair clients out of danger Maintaining injured clients' respiratory status manually until removed from the fire area

During a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall? •Apply restraint to prevent ambulating without assistance •Discontinue all medications to remove the risk of polypharmacy •Assess the circumstances of the fall, including feelings and setting •Require family members to remain at the bedside to watch over the client

Assess the circumstances of the fall, including feelings and setting

Which factor would the nurse consider when counseling an older adult on how often to take a tub bath? • Condition of the skin • Ability of the client to provide self-care • Degree of orientation to the environment • Type of allergic reactions experienced by the client

Condition of the skin

Which signs and symptoms are observed in the human body with a decrease in body temperature? Select all that apply. One, some, or all responses may be correct. •Shivering •Profuse sweating •Flushed appearance •Dilation of blood vessels •Contraction of blood vessels

Contraction of blood vessels

Which intervention by the nurse would be beneficial to promote a healthy lifestyle in an older adult client who lives alone at home and refrains from physical activity for fear of falling when walking ? Select all that apply. One, some, or all responses may be correct. Instruct the client to apply bedside rails. Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Ask the client to install handrails in the bathroom. Help the client rearrange furniture in the house.

Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Help the client rearrange furniture in the house

Which safety topic would the nurse include when providing information to parents of an 8-year-old regarding bicycle safety? Select all that apply. One, some, or all responses may be correct. •Helmet use •Hand signals •Crossing signs •Reflective lights •Close-toed shoes

Helmet use Hand signals Crossing signs Reflective lights Close-toed shoes

Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct. Providing a cold bath to reduce the client's body temperature. Positioning the bed in a low position and keeping the side rails up. Monitoring vital signs, such as blood pressure to decrease the risk of falls. Observing a client who has suicidal tendencies to prevent adverse incidents. Collaborating with family members to provide emotional support for the client post-surgery.

Positioning the bed in a low position and keeping the side rails up. Monitoring vital signs, such as blood pressure to decrease the risk of falls. Observing a client who has suicidal tendencies to prevent adverse incidents.

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver of an older client who requires the use of a walker with wheels? Select all that apply. One, some, or all responses may be correct. •Remove cords. •Apply bed alarms. •Use bright lighting. •Get rid of throw rugs. •Keep phone close by.

Remove cords. Use bright lighting. Get rid of throw rugs.

Diagnosed with chronic obstructive pulmonary disease (COPD), a 50-year-old client's clinical data after treatment is: heart rate of 100 beats/min, blood pressure of 138/82 mm Hg, respiratory rate of 32 breaths/min, tympanic temperature 98.2°F (36.8°C), and an oxygen saturation of 80%. Which vital sign obtained by the nurse indicates a positive outcome? Select all that apply. One, some, or all responses may be correct. Radial pulse: 70 beats/min Temperature: 98.6°F (37°C) Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg • Oxygen saturation: 92%

Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92%

After teaching a group of new nurses about ways of making care visible, the nurse leader observes one of the nurses holding the hand of a client who was anxious before radiation therapy. Which applied skill does the new nurse utilize to reflect effective learning? • Expressing appreciation • Using blameless apology • Showing nonverbal care • Making clear a positive intent

Showing nonverbal care

Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. One, some, or all responses may be correct. •"Use a cane for support when walking." •"Hold on to handrails while ambulating." •"Look where your feet are placed while walking." •"Wear shoes that give good support while walking." •"If you are unable to change your position frequently, request assistance."

"Hold on to handrails while ambulating." "Look where your feet are placed while walking." "Wear shoes that give good support while walking." "If you are unable to change your position frequently, request assistance."

The nurse has provided instructions about back safety to a client. Which statement by the client indicates understanding of these instructions? • " I will bend using my back to lift objects." • "I will sleep on my stomach with a firm mattress." • "I will carry objects close to my body." • "I will pull rather than push when moving heavy objects."

"I will carry objects close to my body."

Which response would the nurse give to the common statement "But you don't understand" when caring for an adolescent? • "I don't understand what you mean." • "I.do understand; I was a teenager once too." • "It would be helpful to understand; let's talk." • "It's you who should try to understand others

"It would be helpful to understand; let's talk."

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place? • "The restraints will be removed once the client is extubated." • "We are required to restrain all clients with breathing tubes." • "Restraints are a last resort to prevent accidental extubation." • "It is routine procedure for us to restrain all intubated clients."

"Restraints are a last resort to prevent accidental extubation."

Which education would the nurse provide the parent of a preschooler about safety? Select all that apply. One, some, or all responses may be correct. •"Have your child sleep on their back or side." •"Teach your child physical safety rules." •"Allow your child to be friendly to strangers." •"Remove doors from unused refrigerators and freez •"Avoid teaching your child to cross roads and walk in parking lots."

"Teach your child physical safety rules." "Remove doors from unused refrigerators and freezers."

The registered nurse (RN) reviews the various sites for assessing body temperature with unlicensed assistive personnel (UAP). Which UAP's statement reflects effective learning? Select all that apply. One, some, or all responses may be correct. "The axilla is recommended to measure body temperature in unconscious clients." 'The oral cavity is suitable for clients with epilepsy to measure body temperature." "The tympanic membrane is a preferred site of measuring body temperature in infants." "The rectum is a preferred site of measuring body temperature in clients who underwent rectal surgeries." 'The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature."

"The axilla is recommended to measure body temperature in unconscious clients." "The tympanic membrane is a preferred site of measuring body temperature in infants." 'The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature."

Which statements) related to initial assessment of blood pressure by the nurse require(s) correction? Select all that apply. One, some, or all responses may be correct. • "Deflating the cuff too slowly will show false high diastolic readings." "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." "If the blood pressure in the left arm is 110/80 mm Hg and in the right arm it is 130/80 mm Hg, it is reportable." "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure." "It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80 mm Hg in the right arm."

"The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure."

Upon finding a client is restless at night, has muscle spasms, and is at risk of falling out of bed, the nurse obtains a provider's prescription for restraints. In which order would the nurse apply the prescribed restraints? Apply a proper-sized restraint according to the manufacturer's direction Pad any skin and bony prominences that will be under the restraint Secure the restraint with a quick-release tie without making a knot Adjust the bed to a proper height and lowering the side rail on the side of client contact Attach restraint straps to the portion of the bed frame that moves while raising or lowering the head of the bed Assess proper placement of the restraint, skin integrity, pulses, skin temperature, color, and sensation of body parts

1) the nurse would first adjust the bed to a proper height and lower the side rail on the side of client contact. 2) nurse would pad the skin and bony prominences that will be under the restraint. 3) The restraint would be applied according to the manufacturer's directions. 4) The nurse would then attach restraint straps to the portion of the bed frame that moves when the head of the bed is raised or lowered. 5) The restraint would then be secured with a quick-release tie. 6) the nurse would check proper placement of the restraint, skin integrity, pulses, skin temperature, color, and sensation of the body part that is restrained.

Which strategies will promote safety and quality of client care on the unit? Select all that apply. One, some, or all responses may be correct. Communicate with clarity and precision when designing multidisciplinary plans of care. Create a safety huddle so all health care professionals are aware of the clinical objectives. Emphasize electronic communication is quick and most effective means of sharing information in all situations. Conduct communication simulations to increase knowledge about expertise of other health care disciplines. communication. Explain effective communication will take more time and effort compared with ineffective

Communicate with clarity and precision when designing multidisciplinary plans of care. Create a safety huddle so all health care professionals are aware of the clinical objectives. Conduct communication simulations to increase knowledge about expertise of other health care disciplines.

Which nursing intervention would be the highest priority for an assault victim? •Monitoring the client's vital signs •Performing a general physical examination •Ensuring the client's emotional and physical safety •Counseling the client regarding sexually transmitted infections

Ensuring the client's emotional and physical safety

Which action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? • Assess the client's ability to understand the nurse. • Evaluate how well the nurse uses active listening. • Reinforce to the client the importance of sharing. • Review the nurse's use of questioning techniques.

Evaluate how well the nurse uses active listening.

The nurse has provided teaching to a client who has impaired balance and uses a walker. • Which observation of the client would indicate to the nurse that further teaching is required? • Slides toward the edge of the seat before standing • Holds both handles of the walker while rising to stand • Moves forward into the walker after transferring from sitting to standing Stands in place holding on to the walker for at least 30 seconds before walking

Holds both handles of the walker while rising to stand

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe? • Instruct the client to position one arm on each shoulder of the nurses. • Direct the client to extend the legs and remain still during the procedure. • Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. Position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of the bed, and then move the client.

Position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of the bed, and then move the client.

The nurse is caring for a two days post-surgery hip-replacement client who has had a bowel movement. Which nursing intervention would the nurse perform next? •Provide perineal care. •Turn and position the client. •Give a complete bed bath. •Document the bowel movement.

Provide perineal care.

Which instruction provides a client the best description of how to use a prescribed, stationary (nonrolling) walker? Place the walker's back leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward. Move the walker about an arm's length ahead while stepping forward and transferring body weight to all walker leg tips. V Put the walker's front leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward. Position the walker's front leg tips onto the floor about an arm's length ahead of the feet and step forward until all tips touch the floor.

Put the walker's front leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse assesses the recorded vital signs. Which vital sign assessment requires reassessment? Select all that apply. One, some, or all responses may be correct. •Respiratory rate of 14 breaths/minute •Blood pressure of 120/80 mm Hg •Oxygen saturation of 95% •Temporal temperature of 99.3°F (37.4°C) •Radial pulse rate of 72 and irregular

Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mm Hg Oxygen saturation of 95%

Atter presenting information about falls risk assessments to nursing staff, which participants statement needs review for corrective action? •"We will assess every admission to the unit." •"We will implement a valid falls risk assessment tool." •"We will apply yellow wrist bands to high-risk clients." •"We will use the admission fall assessment for the entire stay."

"We will use the admission fall assessment for the entire stay."

Which response would the nurse make when obtaining a health history from a client who is known to be verbally abusive and says, "You're ugly, and you're probably stupid, too. Why am I stuck with you"? • "It doesn't matter what you think, because I know I'm a capable nurse." • "Tell me more about why my caring for you today is so upsetting to you." "If you like, I will arrange to switch assignments so you can have another nurse." "You are talking inappropriately, sò l'm going to leave and will come back when you stop being verbally abusive."

"You are talking inappropriately, sò l'm going to leave and will come back when you stop being verbally abusive."

Which feedback given by the registered nurse (RN) to the delegatee is constructive? Select all that apply. One, some, or all responses may be correct. •"Well done. Nice job." •"I expected you to do better." •"You can do better when you concentrate." •"You performed that procedure safely and professionally." •"Let me demonstrate a more effective way to perform the task."

"You performed that procedure safely and professionally." "Let me demonstrate a more effective way to perform the task."

In which order would the nurse follow steps of risk management to identify potential hazards and to eliminate them before harm occurs? •Analyzing the possible risks •Identifying possible risks •Evaluating the steps taken •Acting to reduce the risks

1) Identifying possible risks 2) Analyzing the possible risks 3) Acting to reduce the risks 4) Evaluating the steps taken

According to Maslow's hierarchy of needs, in which order would the nurse prioritize actions? •Encouraging the client to talk about fears and feelings •Providing a warm bath to the client to promote a good night's sleep •Assisting the client in getting out of bed to join family members for meals •Praising the client for administering insulin accurately

1) Providing a warm bath to the client to promote a good night's sleep 2) Encouraging the client to talk about fears and feelings 3) Assisting the client in getting out of bed to join family members for meals 4) Praising the client for administering insulin accurately

Which nursing action is most appropriate to help reduce the likelihood of an older adult client falling during the night? •Moving the client's bedside table closer to the bed Encouraging the client to take an available sedative •Instructing the client to call the nurse before going to the bathroom •Assisting the client to telephone home to say goodnight to the spouse

Instructing the client to call the nurse before going to the bathroom

Which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day? • Sustained • Relapsing • Remittent • Intermittent

Intermittent

Which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day? •Sustained •Relapsing •Remittent •Intermittent

Intermittent

A child swallowed a poisonous substance and has fallen unconscious. Which nursing intervention is advisable for the child? •Administer ipecac immediately. •Run tap water over the child's face for some time. •Make a call to the national poison control hotline. •Make arrangements for the child to be taken to a hospital.

Make arrangements for the child to be taken to a hospital.

The nurse provides crutch-walking instructions to a client who has a left-leg cast. Where would the nurse teach the client to place their weight? • In the axillae • On the hands • On the right side • On the side that the client prefers

On the hands

A client with left-sided weakness is learning how to use a cane. The nurse would demonstrate proper use of the cane by holding it where? •On alternating sides •On the right side •On the side with weakness •On the side of the client's choice

On the right side

A client asks about the purpose of a pulse oximeter. Which measurement is a pulse oximeter used for? •Respiratory rate •Amount of oxygen in the blood •Percentage of oxygen-carrying •hemoglobin •Amount of carbon dioxide in the blood

Percentage of oxygen-carrying hemoglobin

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is priority when the client becomes short of breath during the care? • Obtain a pulse oximeter to determine the client's oxygen saturation level. • Put the client in a high Fowler position. • Darken the lights and provide a rest period of at least 15 minutes. • Continue the hygiene activities while reassuring the client.

Put the client in a high Fowler position.

Which level of Maslow's hierarchy of needs is the nurse using when teaching the client about the call light system? •Safety •Self-esteem •Physiological •Interpersonal

Safety

After a home assessment of an older adult's fall risk, which intervention would the nurse suggest? Select all that apply. One, some, or all responses may be correct. • Dimming lighting to avoid squinting • Secure rugs to prevent movement • Remove excessive pieces of furniture • Wear corrective lenses for distance vision • Perform exercises to strengthen lower extremities

Secure rugs to prevent movement Remove excessive pieces of furniture Wear corrective lenses for distance vision Perform exercises to strengthen lower extremities

Which site would be safer and less expensive for temperature measurement of a human? •Skin •Oral •Axilla •Rectal •Tympanic membrane

Skin Axilla

Which clinical finding demonstrates to the nurse that the client can use a standard walker? • Weak upper arm strength and impaired stamina • Weight bearing as tolerated and unilateral paralysis • Partial weight bearing on the affected extremity and kyphosis • Strong upper arm strength and non-weight bearing on the affected extremity

Strong upper arm strength and non-weight bearing on the affected extremity

The nurse is managing care for a client who has had a total hip arthroplasty. Which action by the unlicensed assistive personnel (UAP) will require the nurse to intervene? • The client's heels are kept off the bed. • The UAP elevates the client's affected leg on a pillow. • The UAP uses a pillow to keep the client's legs abducted. • The client uses a walker when ambulating with the UAP.

The UAP elevates the client's affected leg on a pillow.

Which legal implication would the nurse understand about applying restraints to a client? •The law allows restraining clients until a written prescription is obtained. •A felony charge may be leveled against nurses who use any kinds of restraints. •Nurses are not obligated to report institutions that use restraints unlawfully. •The nurse can be charged with assault and battery for using restraints improperly.

The nurse can be charged with assault and battery for using restraints improperly.

Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship? •The self and a desire to help •Knowledge of psychopathology •Advanced communication skills •Years of experience in psychiatric nursing

The self and a desire to help

The registered nurse notices a new employee, who is obtaining the blood pressure of a client, is deflating the cuff too rapidly. If the actual blood pressure of the client was 140/90 mm Hg, which blood pressure reading is the new employee most likely to have obtained? •130/80 mm Hg •150/100 mm Hg •140/100 mm Hg •130/100 mm Hg

130/100 mm Hg

After recording the blood pressure of a client, the primary health care provider confirms a diagnosis of pheochromocytoma. Which blood pressure reading may have helped confirm the diagnosis? • 90/70 mm Hg • 80/60 mm Hg • 120/80 mm Hg • 190/90 mm Hg

190/90 mm Hg

Which blood pressure would the nurse recognize as normal in toddlers? • 85/54 mm Hg • 95/65 mm Hg • 105/65 mm Hg • 110/65 mm Hg

95/65 mm Hg

When the nurse is making a home visit to a family with a toddler, which finding indicates a need for education about home safety? •Fire extinguishers •Unlocked cabinets •House built in 2000 •Front-facing car seat

Unlocked cabinets

When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize? • Using medical terminology • Proceeding in an unhurried manner • Speaking in a low and moderate voice • Pantomiming words and simple actions while verbalizing them

Using medical terminology

A client who had an open reduction and internal fixation of a femoral neck fracture has a prescription for ambulation with slight weight bearing on the affected extremity. The nurse identifies that the client has kyphosis and strong upper-arm strength. Which assistive device would the nurse expect the primary health care provider to prescribe? • Crutches. • Quad cane. • Straight cane • Walker

Walker

Which point requires correction regarding the use of restraints? •Less restrictive interventions must have been unsuccessful before applying restraints. •All other alternatives must have been tried and exhausted before applying restraints. •Restraints may be applied to ensure the physical safety of the resident or other residents. •A written order for restraints is not required.

A written order for restraints is not required.

Which method would the nurse teach a client on a rehabilitation unit after a cerebrovascular accident (CVA) with residual hemiparesis to help achieve the goal of safe walking with a cane? • Shorten the stride of the unaffected extremity. • Advance the cane and the affected extremity simultaneously. • Lean the body toward the side with the cane when ambulating. • Hold the cane on the same side as the affected extremity and increase the base of support.

Advance the cane and the affected extremity simultaneously.

Which interventions would the nurse manager include in a fall prevention program to decrease the number of falls on the unit? Select all that apply. One, some, or all responses may be correct. •Apply fall wristband. install bed safety alarms. •Establish a toileting schedule. •Allow client to ambulate to bathroom. •Use restraints to prevent the client from leaving the bed.

Apply fall wristband. nstall bed safety alarms. Establish a toileting schedule.

At which site would the nurse obtain the temperature of a client admitted to a surgical unit in an unconscious state due to head trauma? • Oral • Axilla • Temporal artery • Tympanic membrane.

Axilla

The nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. Which step would the nurse do next after placing the nurse's arms under the client's axillae? •Bending and then straightening their knees •Bending at the waist and then straightening the back •Placing one foot in front of the other and then leaning back •Placing pressure against the client's axillae and then raising their arms

Bending and then straightening their knees

Which condition would the nurse associate with a client's regular and slow respiratory rate? • Apnea • Bradypnea • Tachypnea • Hyperpnea

Bradypnea

Which safety factor would the nurse teach parents about using a crib for an infant? •Ensure the crib has a drop-side rail. •Place soft toys and soft pillows inside the crib. •Attach toys with hanging strings over the crib. •Check that the slats are less than 6 cm (2.4 inches) apart.

Check that the slats are less than 6 cm (2.4 inches) apart.

Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? • Answer the client's call light immediately to prevent incontinence. • Place a waterproof pad under the client to prevent soiling the linens. • Check the client's buttocks at least every 2 hours and clean after incontinence. • Offer toileting to the client every 2 hours to prevent incontinence.

Check the client's buttocks at least every 2 hours and clean after incontinence.

The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment (PPE) would the nurse wear? • Mask • Clean gloves • Sterile gloves • Shoe covers

Clean gloves

The nurse palpated the peripheral pulse of four different clients. Which client has an unacceptable heart rate?

Client 3

How can the nurse evaluate the effectiveness of communication with a client? •Client feedback •Medical assessments •Health care team conferences •Client's physiological responses

Client feedback

The nurse is working with a client who reports intimate partner violence and shares being afraid to leave the partner. Which information would the nurse discuss with the client to increase safety? Select all that apply. One, some, or all responses may be correct. •Change the locks on the doors. •Avoid local area stores. •Develop an escape plan. •Obtain a restraining order. •Have important phone numbers.

Develop an escape plan. Have important phone numbers.

Which findings indicate that the nurses are providing safe health care? Select all that apply. One, some, or all responses may be correct. •Exhibits good decision-making skills •Acts within the scope of practice of their license •Provides cost-effective interventions to the clients •Offers both curative and preventive interventions for the clients •Executes interventions that have reduced the duration of hospital stays of the clients

Exhibits good decision-making skills Acts within the scope of practice of their license

The nurse expects a client with an elevated temperature to exhibit which indicator of pyrexia? Select all that apply. One, some, or all responses may be correct. •Dyspnea •Flushed face •Precordial pain •Increased pulse rate •Increased blood pressure

Flushed face Increased pulse rate

Which extrinsic factor is responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. •Impaired vision •Cognitive impairment •Environmental hazards •Inappropriate footwear •Improper use of assistive devices

Inappropriate footwear Improper use of assistive devices