Final Exam - Quizzes
A nurse receives a report for a client who is going to surgery in the morning. The nurse is informed that the client is Jehovah's Witness. What education is needed for this particular client? 1) The client needs to be informed that blood may be given if needed in an emergency situation so informed consent can be obtained. 2) The client should be informed that surgery is not an option because blood will need to be transfused. 3) The client needs to have a discussion with the health care team about blood product preferences. 4)The client should be informed that he or she can discuss the possible need for blood with a spiritual counselor prior to surgery to make an informed decision.
1 Although the client is Jehovah's Witness, the nurse needs to initiate a discussion with the client about administration of blood and blood products. The nurse should not stereotype and assume the client will refuse all blood products. The client should be informed about choices and given options prior to surgery. These options should be provided without judgement or personal opinion. If the client chooses to refer to a spiritual counselor, this should be provided, but this is not education needed.
The nurse is caring for a client who has died. What legal responsibility should the nurse address as part of postmortem care? (Select all that apply.) 1) Label the body. 2) Arrange for organ donation protocol to be followed. 3) Notify the funeral home. 4) Provide a private environment for the family to view the client.
1 & 2 Legal responsibilities of the nurse after a client dies include labeling the body, arranging for organ donation protocol to be followed, and ensuring that the death certificate is completed. The family or other designated person notifies the funeral home. Providing a private environment for the family to view the body of the deceased client is a part of caring and not a legal responsibility after a death.
The client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn pain. The client rates the pain as a 7 on the numeric scale of 0/10. How many tablets of oxycodone/acetaminophen should the nurse administer? 1) 2 2) 8 3) 4 4) 6
1) 2 The nurse should administer 2 tablets for pain greater than 5 on a numeric scale of 0/10.
The physician ordered 180 mg of Dilantin oral solution every 8 hours. The patient weighs 98 lb. The label of the drug reads 250 mg per 5 mL. How many millilitres will you administer to this patient per dose? 1) 3.6 2) 4.9 3) 0.36 4) 0.72
1) 3.6
A 4-year-old child is brought into the emergency room for abdominal pain. While in the emergency department, the client's condition deteriorates and the child dies. After the physician pronounces the time of death, the child's parent punches a hole in the wall of the exam room. Which stage of grief is the parent experiencing? 1) Anger 2) Acceptance 3) Denial 4) Depression
1) anger The parent of the child is experiencing the anger stage of grief, and is expressing anger that the child died through physical action, such as punching a hole in the wall. The anger stage is characterized by feelings of anger, and even expressing this pain and anger at others. The denial stage is characterized by feeling of shock and numbness, just trying to get through each day and survive the grief. Depression would be characterized by withdrawal from life and loved ones, feelings of intense sadness, and feeling like there is no reason to go on. Acceptance is accepting the new reality, beginning to live and enjoy life again.
A nurse is caring for a client diagnosed with sleep apnea. What should the nurse do in order to promote sleep in the client? 1) Avoid sedatives for sleeping. 2) Encourage the client to lose weight. 3) Encourage deep breathing exercises. 4) Provide good ventilation in the room.
1) avoid sedatives for sleeping Clients with sleep apnea already have difficulty maintaining oxygen levels in the blood giving them a sedative can cause them to decrease oxygen levels even more as the respiratory drive is diminished.
A client responds to an approaching diagnostic test with a rapidly beating heart and hands that are shaking. This is the result of what type of response? 1) Coping responses 2) Stress adaptation 3) Defense mechanism 4) Withdrawal behavior
1) coping responses Increased heart rate is part of the bodies normal coping response to stress. Part of the sympathetic nervous system response includes increase heart rate and blood pressure and pupil dilation.
A nurse educator is teaching a class about patient hygiene and grooming to nursing assistants. What problem can be prevented by daily brushing of the patient's hair that the nurse needs to include in the teaching? 1) Dandruff 2) Alopecia 3) Tangles 4) Pediculosis
1) dandruff 1. Pediculosis is caused by direct contact with lice or their eggs (nits); brushing the hair will not prevent head lice. 2. Shampooing the hair and rubbing the scalp help to limit dandruff. 3. Loss of hair (alopecia) may be caused by nutritional, emotional, iatrogenic, and genetic factors; it is not prevented by brushing. 4. Brushing separates tangles and evenly distributes secretions and oils down the hair shafts.
A nursing instructor is describing the difference between sleep and rest. Which characteristic would the instructor identify as distinguishing sleep from rest? 1) decrease in awareness of environment 2) decrease in motor response to stimuli 3) involves all the body systems 4) decrease in cognitive response to stimuli
1) decrease in awareness of environment
A nurse is making a home visit to an older adult with multiple chronic health problems. The client is alert and oriented and his cognition is intact. While talking with the client, he reveals that he thinks his son is stealing his social security checks to buy his beer and eat out all the time. The nurse interprets this statement as possibly suggesting which type of elder abuse? 1) Exploitation 2) Physical 3) Abandonment 4) Emotional
1) exploitation Exploitation involves illegally taking or misusing the funds, property, or assets of a vulnerable older adult (fiscal abuse). Physical abuse involves the infliction of pain/injury on a vulnerable older adult, the threat of inflicting such pain or injury, or depriving them of basic needs. Emotional/psychological abuse involves verbal or nonverbal actions causing mental pain, anguish, or distress on the older adult. Abandonment involves desertion of a vulnerable adult by anyone who has assumed responsibility for his care.
A friend has lost her job and is becoming increasingly anxious to the point of crisis. What type of crisis is she experiencing? 1) Situational 2) Maturational 3) Adventitious 4) Emotional
1) situational
A single parent has only one child. The parent shares dreading the fall when the child leaves for college. Which type(s) of loss is this client likely to experience? (Select all that apply.) 1) Maturational loss 2) Perceived loss 3) Situational loss 4) Actual loss 5) Anticipatory loss
1, 2, & 5 This client would be experiencing perceived, psychological, maturational and anticipatory losses. This situation describes one of a perceived and psychological loss rather than an actual loss, as the child is not dying or leaving forever. The parent just perceives a change in relationship. This is a classic maturational loss scenario, as it is a result of the normal development process. As the parent knows about this loss prior to it happening, the parent is anticipating the loss and therefore experiencing anticipatory loss also. Actual loss is a loss that can be recognized by others as well as the person suffering the loss, such as the loss of a limb, loss of a child, money or job. Perceived loss is felt by the person, but intangible to others, such as loss of youth, financial status or a valued environment. Physical and psychological losses are directly related to actual and perceived losses. Physical loss involves the loss of something tangible such as a limb or job, and psychological loss involves the altered self-image and inability to return to a previous job due to the loss of a limb or other loss. These losses are simultaneous. Situational loss is experienced as a result of an unpredictable event, such as a traumatic injury, disease, death or natural disaster. Anticipatory loss occurs when a person displays loss and grief behaviors before the loss has taken place, such as client with cancer mourning the loss of her hair before it occurs. Maturational loss is experiences as a result of natural development processes, such as the loss a parent experiences when sending a child to kindergarten or college, or the loss a first child experiences when a sibling is born.
The nursing student is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? (Select all that apply) 1) Where exactly is the pain? 2) How long does the pain last? 3) Have you taken any medications for the pain? 4) Does anyone else you know have pain like this?
1, 2, 3
A nursing student is teaching her client how to complete proper hand hygiene. The client asks "What is the shortest amount of time that I should scrub my hands if they are not obviously dirty?" What is the best response by the nursing student? 1) 20 seconds 2) 15 minutes 3) 5 minutes 4) 5 seconds
1, 20 seconds
Which of the following defines nursing as a profession? 1) a strong service orientation 2) an ability to diagnose medical problems 3) a dependence on the medical profession 4) an undefined body of knowledge
1, a strong service orientation Nursing is a profession as evidenced by a strong service orientation, autonomy, a code of ethics and a defined body of knowledge.
A nurse answers questions a client has about his condition so he can choose his course of treatment. The nurse does not offer her opinion and allows the client she is caring for to make his own choice. What is this principle known as? 1) autonomy 2) Nonmaleficence 3) Fidelity 4) Justice
1, autonomy
A nurse is caring for a young victim of a terrorist attack. During the rehabilitative process, the nurse assists the client in bathing and dressing. What role the nurse is engaged in? 1) caregiver 2) educator 3) advocate 4) counselor
1, caregiver
A nursing instructor asks the student to explain the concept of health. Which of the following statements made by the student accurately describes this concept? 1) Health is a state of optimal functioning. 2) Health is an absence of illness. 3) Health is always an objective state. 4) Health is not determined by the client.
1, health is a state of optimal functioning Health is more then just the absence of illness it is a state of optimal functioning, it is subjective and is determined by both the client and health care provider.
A client has a prescription for lorazepam 50 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit? 1) negligence 2) assault 3) beneficence 4) battery
1, negligence Negligence it caused harm, and was not provided using the correct route.
Which independent nursing actions are associated with caring for a patient who is experiencing hypoxemia? (Select all that apply.) 1) Encourage the patient to cough when the patient has secretions. 2) Remain calm and speak in a normal tone of voice. 3) Attach a pulse oximeter to the patient's finger. 4) Administer oxygen at 4 L/minute via a nonrebreather mask. 5) Elevate the head of the bed.
1,2,3, 5 1. Elevating the head of the bed is an independent nursing action. It does not require an order from a primary health-care provider. Raising the head of the bed uses gravity to move abdominal organs away from the diaphragm, facilitating respirations. 2. This is an independent function of the nurse. The nurse does not need an order from a primary health-care provider to monitor a patient's oxygen saturation level. 3. These are independent functions of the nurse. Impaired oxygenation is a frightening experience. It is important for the nurse to remain calm and not contribute to the patient's fear and/or anxiety. 4. The nurse can administer 2 L/minute of oxygen by nasal cannula in an emergency without an order from a primary health-care provider. Other oxygen delivery systems, such as a nonrebreather mask or elevating the oxygen level higher than 2 liters per minute, require an order from a primary health-care provider. 5. Coughing facilitates expulsion of secretions from the respiratory tract. When secretions are cleared from the respiratory tract, more air can be inhaled into the alveoli and carbon dioxide exhaled
The nurse reviews a physician's order and finds that the medication amount is greater than the standard dose. What should the nurse do? 1) Call the physician to discuss the order. 2) Inform the nursing supervisor. 3) Give the standard dose rather than the one that is ordered. 4) Give the drug as ordered by the physician.
1. call the physician to discuss the order
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from an accident. Which of the following is objective data? 1) unable to palpate femoral pulse in left leg 2) my leg hurts so bad I can't stand it 3) I am so sick, I am about to throw up 4) appears anxious and frightened
1. unable to palpate femoral pulse in left leg Objective data is something the nurse can observe or validate independently. Subjective data is something the client says and cannot be validated.
how many mg in a g?
1000
how many ml in a tablespoon?
15 ml
An older adult has hearing loss and a sensation of fullness in both ears. The nurse should examine the ears for: 1) inflammation of the external canal. 2) accumulation of cerumen in the external canal. 3) presence of a bony growth in the ear. 4) accumulation of cerumen in the internal canal.
2) accumulation of cerumen in the external canal Cerumen (ear wax) commonly gets impacted in older clients in the external canal. Otalgia is the "fullness" sensation or pain that an older client may experience when the cerumen becomes impacted.External otitis is an inflammation of the outer ear and would not explain the symptoms the client is experiencing.A bony growth (exostosis) arises from the surface of a bone and would not explain the symptoms the client is experiencing.
A family has recently immigrated. All members are quickly learning the language and the children are all in public school. Both parents are working and adapting to the new culture. What is this family demonstrating? 1) Culture shock 2) Cultural assimilation 3) Cultural imposition 4) Cultural blindness
2) cultural assimilation When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different and take on the values of the dominant culture. This process is called cultural assimilation.
A primary health-care provider orders oxygen 4 L/minute via nasal cannula. What nursing action is essential? 1) Position the prongs in the patient's nares so that they curve upward. 2) Ensure that the oxygen is humidified. 3) Provide oral hygiene every shift. 4) Secure elastic straps around the patient's head.
2) ensure that the oxygen is humidified 1. The curved prongs should be positioned in the nose with the curve facing downward. This follows the natural curve of the internal pathway of the nose. 2. A nasal cannula oxygen delivery system does not include elastic straps. The tubing of a nasal cannula iswrapped around the ears and the slider is positioned under the chin. 3. An oxygen flow rate higher than 3 L/minute can dry the mucous membranes. Humidification of oxygen helps minimize drying of the mucous membranes. 4. Oral care should be provided every 4 hours because oxygen therapy can dry mucous membranes. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word essential in the stem sets a priority. Identify the clang association. The word oxygen in the stem and in option 3 is a clang association.
The clinic nurse is explaining the action of sildenafil (Viagra) to a client. The nurse should assess his medication regimen to determine if he is taking medications that are contraindicated with sildenafil. Which of the following medications is contraindicated with sildenafil? 1) Diuretics 2) Nitrates 3) MAO inhibitors 4) Amoxicillin
2) nitrates One concern with sildenafil is its potential to cause hypotension. It is contraindicated in men who take nitrates or use nitrate patches.
During hospitalization for a suicide attempt, the client informs the nurse that she does not want to return to work because her boss expects sexual favors each week before he gives her a paycheck. The client informs the nurse that she needs the job but is embarrassed that she performs these favors. The nurse informs the client that this is illegal behavior and is called what? 1) Fetishism 2) Quid pro quo harassment 3) Environmental harassment 4) Hostile environment harassment
2) quid pro quo harassment Quid pro quo means that something is given or withheld in exchange for something else. It generally occurs when a person in a position of authority offers either direct or indirect reward or punishment based on the granting of sexual favors. Environmental harassment and hostile environment harassment are identical situations and occur when workplace behaviors of a sexual nature create a hostile, intimidating environment that interferes with a person's work performance. Fetishism is sexual arousal with the aid of an inanimate object not generally associated with sexual activity.
A nurse finishes assisting a patient with a complete bed bath. What is most important for the nurse to do before leaving the patient's room, besides moving the bed to its lowest position? 1) Pull all the side rails up on both sides of the patient's bed. 2) Secure the call bell within easy reach. 3) Leave the door to the patient's room open. 4) Place the overbed table next to the bed.
2) secure the call bell within easy reach Rationales: 1. It is most important that a patient have the ability to call for help when needed. It is a major safety issue. 2. Although moving the overbed table next to the patient's bed is helpful, it is not essential. 3. The patient may prefer to have the door closed. The nurse should determine the patient's preference. 4. Pulling up all of the side rails of a bed without the patient's consent is considered a restraint. A nurse can engage all of the side rails of a bed if it is necessary to maintain the safety of the patient, but the need for their use must be documented.
Which of the following statements best describes the relationship between biologic sex and gender identity? 1) Biologic sex and gender identity are both modifiable by surgery and medical interventions. 2) Sex is chromosomally determined, while gender is a psychosocial construct. 3) Biologic sex is genetically determined but gender identity is chosen during adolescence. 4) Biologic sex and gender identity are considered synonymous in nursing practice.
2) sex is chromosomal determined, while gender is a psychosocial construct Biologic sex is the term used to denote chromosomal sexual development. Gender identity is the inner sense a person has of being male or female. As such, biologic sex is amenable to medical interventions, but surgery and hormone therapy will not change an individual's inner sense of being male or female. Gender identity is not commonly thought to be chosen or objectively selected during adolescence.
During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. What is the best response by the nurse? 1) "I can have the social worker talk to you if you would like." 2) "Tell me more about your feelings on this." 3) "You might feel better if you confided in your husband." 4) "Cancer is not a punishment; it's a disease."
2) tell me more about your feelings on this. The nurse should respond with an open-ended statement that elicits further exploration of the client's feelings. Women with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict the client's feelings of punishment or offer advice such as confiding in the husband. A social worker referral may be beneficial in the future, but it is not the first response needed to elicit exploration of the client's feelings.
A client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next? 1) Continue to drain the bladder until empty. 2) Clamp the catheter for 20 minutes. 3) Remove the catheter and document the output. 4) Pinch the catheter to slow the flow of urine.
2). clamp the catheter for 20 minutes Taking a large amount of urine from the bladder over a short period of time puts the client at risk for hypovolemic shock. The other options would not prevent hypovolemic shock. The only way to gradually remove urine is to clamp and unclamp the catheter.
A nurse is assessing a patient with chronic pain. What clinical indicators should the nurse expect the patient to exhibit? (Select all that apply.) 1) Dilated pupils 2) Variable breathing patterns 3) Gradual onset 4) Recurrent in nature 5) Pressured speech
2, 3, 4 1. A gradual onset is associated with chronic pain. A quick onset is associated with acute pain. 2. Constricted pupils are related to parasympathetic nervous system associated with chronic pain. Dilated pupils are associated with acute pain. 3. Pressured speech is related to stimulation of the sympathetic system associated with acute pain. slow monotonous speech is associated with chronic pain. 4. Recurring pain is associated with remissions and exacerbations, which are related to chronic pain. Chronic pain is related to a time frame longer than 6 months. 5. Variable breathing patterns are associated with chronic pain in response to stimulation of the parasympathetic nervous system. Hyperpnea is related to acute pain in response to stimulation of the sympathetic nervous system. TEST-TAKING TIP: Identify the options that are opposites. Options 2 and 4 are opposites. One or the other should be eliminated; rarely are both opposite options correct
The nurse has delegated providing postmortem care of an adult client to an unlicensed assistive personnel (UAP). The nurse does not expect an autopsy however has not verified this with the coroner yet. Which instructions should the nurse give to the UAP who will provide postmortem care for this client? (Select all that apply.) 1) Remove all indwelling lines and catheters. 2) Ask the client's family if they have any requests for how to prepare the body. 3) The family may remain with the client as long as they need. 4) Elevate the head of the bed as soon as possible.
2, 3, 4 In some cultures the family may wish to remain with the body for several hours after a family member's death. The nurse should consult with the family about any preparation requests such as wearing special clothing or jewelry. It is important to elevate the head of the bed to prevent pooling of blood and discoloration from pooling blood. Indwelling lines should not be removed until the nurse is certain an autopsy will not be performed..
The nursing students overhears a nurse at her long term care clinical site loudly tell a client "If I have to get you up to use the commode one more time I am going to catheterize you, I don't have time for this today." The nursing student immediately informs her clinical instructor and understands the nurse can be litigated for what? 1) Battery 2) Assault 3) Invasion of Privacy 4) Dereliction of duty
2, assault Battery is an unlawful touching of the person's body without consent. Assault is a verbal attack or unlawful threat causing a fear of harm. No actual contact is necessary for a threat to be an assault.
Explain what a nurse practice act is? In what level of government would you find it (federal, state, local)? and what does the nurse practice act provide? SATA 1) governs the legal practice of the CNA 2) state law that is the legal guideline for minimally safe and adequate nursing practice 3) governs the legal practice of the RN 4) defined by each state 5) established to protect the public
2,3,4,5 state law that is the legal guideline for minimally safe and adequate nursing practice, defined by each state, was established to protect the public
The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem? 1) spasms at the orifice of the bladder 2) friction along the urethra when the catheter is being inserted 3) the number of organisms gaining entrance to the bladder 4) the formation of encrustations that may occur at the end of the catheter
2. friction along the urethra when the catheter is being inserted Liberal lubrication of the catheter before catheterization of a male reduces friction along the urethra and irritation and trauma to urethral tissues. Because the male urethra is tortuous, a liberal amount of lubrication is advised to ease catheter passage. The female urethra is not tortuous, and, although the catheter should be lubricated before insertion, less lubricant is necessary. Lubrication of the catheter will not decrease spasms. The nurse should use sterile technique to prevent introducing organisms. Crusts will not form immediately. Irrigating the catheter as needed will prevent clot and crust formation.
A nurse is teaching a group of nursing assistants about infection-control measures. What is the priority information to include in this teaching? 1) proper use of gloves 2) hand-washing techniques 3) administration of antibiotics 4) assignment of private rooms
2. hand washing techniques Hand washing is the first line of intervention for preventing the spread of infection and therefore is the priority for this teaching. Wearing gloves and assigning private rooms for clients may also decrease the spread of infection and should be implemented according to standard precautions. Antibiotics should be initiated when a causative organism is identified, but would not be in the scope of practice for a nursing assistant.
A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for how long? 1) 12 to 14 weeks 2) 1 to 2 weeks 3) 4 to 6 weeks 4) 24 to 26 weeks
3) 4 to 6 weeks Generally, 4 to 6 weeks is viewed as the length of time a client can tolerate the severe level of disturbance of a true crisis. In the first week or two, the client usually is still trying to use normal coping skills and support systems. After 6 weeks of continuous crisis, a client is probably becoming so physically and emotionally drained that the client has sought or has been brought by others for medical or psychiatric care.
Which of the following responses to stressors results from the activation of the local adaptation syndrome? 1) A man is experiencing moderate anxiety before meeting with an important client. 2) A woman's impending job interview has prompted the activation of her fight-or-flight response. 3) A girl quickly withdraws her hand from a stream of hot tap water. 4) A man has a sudden urge for a bowel movement before undergoing thoracentesis.
3) a girl quickly withdraws her hand from a stream of hot tap water
The nurse is observing a spouse administer eye drops. What should the nurse instruct the spouse to do? 1) Have the client squeeze both eyes after administering the drops. 2) Move the dropper to the inner canthus. 3) Administer the drops in the center of the lower lid. 4) Have the client raise the eyebrows.
3) administer the drops in the center of the lower lid The spouse has positioned the dropper and the client correctly to prevent injury to the client's eye. The spouse should administer the drops in the center of the lower lid. Following administration of the eye drops, the client should blink the eyes to distribute the medication; squeezing or rubbing the eyes might cause the medication to drip out of the eye.
Which should the nurse do first before initiating a.m. care with a patient? 1) Feed the patient breakfast. 2) Change the linens on the bed. 3) Ask the patient about preferences. 4) Raise the bed to working height.
3) ask the patient about preferences 1. Asking about the patient's personal preferences allows the nurse to individualize the patient's care. Personalizing a patient's care demonstrates respect and caring. 2. This is premature. Raising the height of the bed may not be necessary if the patient can provide hygiene care independently. 3. The linens should be changed after hygiene care because they can get wet and soiled during care. 4. It is not necessary to eat breakfast before a.m. care. Breakfast can be eaten before or after a.m. care depending on the patient's preference. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word first in the stem sets a priority. Identify the unique option. Option 1 is unique; it is the only option that addresses the patient's psychological needs. Identify the patient centered option. Option 1 is patient centered.
A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction? 1) "What are you doing immediately prior to your sexual encounters?" 2) "Have you always had a hard time obtaining an erection?" 3) "Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?" 4) "Have you had any discharge or pain with urination?"
3) do you take any medications such as antihypertensives, antidepressants, or illicit drugs? Common causes of impotence (which may be physiologic or psychological) include various illnesses, treatments for these illnesses, and personal anxieties. Antihypertensive medication and antidepressant medications are a leading cause of impotence in male clients and it is possible to switch medications to help the client with this problem.
A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse that the client is having difficulty coping? 1) "I'm ready to get this over with." 2) "I'm somewhat afraid to have the surgery, but I feel OK about it." 3) "I'll be glad to have my jaw fixed because my wife thinks I don't look like myself." 4) "My wife will help me, but I don't think I'll need that much help."
3) ill be glad to have my jaw fixed because my wife thinks ii don't look like myself A client should not elect surgery to meet someone else's needs. The nurse should encourage the client to share his feelings and his perception of the deformity and to clarify his reasons for electing to have the surgery. It is normal to be somewhat afraid, and it is good if a client says he feels "OK" about the surgery. The fact that a client believes that his wife will help him after surgery and that he will also be relatively independent reflects appropriate adaptation. It is a common feeling among preoperative clients that they are ready to "get this over with," indicating that the waiting period is stressful.
Which is most important to do when cleaning a patient's dentures? 1) Brush the upper appliance first. 2) Ensure a continuous flow of water. 3) Place a washcloth in the bottom of the sink. 4) Wear sterile gloves.
3) place a washcloth in the bottom of the sink 1. washcloth in the bottom of the sink is the most important action. This minimizes the risk of damaging the denture if the nurse should accidentally drop the denture in the sink. 2. The flow of water does not have to be continuous; it has to flow only when rinsing the denture cleanser off the denture after being cleaned. 3. It does not matter which denture is cleansed first. 4. Clean, not sterile, gloves are necessary to protect the nurse from the patient's oral secretions when cleaning a patient's dentures. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority.
A nurse asks a patient, "What does the pain feel like?" What characteristic of pain is the nurse assessing? 1) Precipitating factors 2) Intensity 3) Quality 4) Behavioral effects
3) quality 1. This question is assessing the quality of the pain. Descriptions generally include such words as burning,stabbing, throbbing, crushing, pressure, sharp, dull, achy, and so on. 2. A question that assesses intensity is, "How severe is your pain on a scale of 0 to 10?" A numerical scale provides objective and consistent assessment of pain intensity. 3. The question does not assess behavioral responses to pain. Observing moaning, grunting, crying, increased muscle tension, hand wringing, guarding, holding or rubbing a part of the body, and so on are examples of observed behaviors associated with a painful experience. 4. A question that assesses precipitating factors is, "What initiates or increases the pain?" Participating factors may include such actions as bending, lifting, coughing, eating, or breathing deeply.
An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism? 1) reaction formation 2) intellectualization 3) regression 4) projection
3) regression An adult who throws temper tantrums such as this one is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source of the anger or frustration or pain. In reaction formation, the client acts in opposition to feelings. In intellectualization, the client over-relies on rational explanations or abstract thinking to diminish the significance of a feeling or event.
An unconscious patient has excessive oral secretions. In which position should the nurse place the patient to help prevent aspiration? 1) Supine 2) Fowler 3) Sims 4) Contour
3) sims 1. The Sims' position is the most effective position to prevent aspiration, particularly in an unconscious patient because excessive oral secretions will drain out of the side of the mouth. In addition, this position will be easy to maintain in a patient who is unconscious. 2. The supine position will not aid in the prevention of aspiration because lying on the back will promote the flow of secretions to the back of the oropharynx and trachea. 3. The Fowler position may assist in the prevention of aspiration but will not be as effective another position. In addition, an unconscious patient may have difficulty maintaining the Fowler position. 4. The contour position will have minimal effect in preventing aspiration because the head will not be elevated enough. In addition, an unconscious patient may have difficulty maintaining this position. TEST-TAKING TIP: Identify the equally plausible options. Options 3 and 4 are equally plausible because both positions elevate the head of the bed and position the body in a sitting position.
The nurse should assess an older adult who has diminished hearing and vision for which condition? 1) feelings of disorientation 2) cognitive impairment 3) social isolation 4) sensory overload
3) social isolation Social isolation is a concern for an older adult who has diminished hearing and vision. Feeling disoriented may be related to cognitive problems rather than diminished hearing and vision. Diminished hearing and vision is related to the aging process and does not result in impairment of the older adult's thought processes. The client with impaired hearing and vision is unlikely to experience sensory overload.
The nurse obtains a client's weight as part of the health history. The client weighs 88 kg. The nurse determines that this client weighs how many pounds? (Please round your answer to the nearest tenth.) 1) 188.7 2) 132.6 3) 193.6 4) 111.4
3, 193.6
The nursing instructor is lecturing on reasons a nurse could have their license revoked or suspended. Which reason is given by the nursing student as the most frequent reason that a nurse's license would be suspended or revoked? 1) criminal activity 2) mental impairment 3) alcohol and drug abuse 4) fraud
3, alcohol and drug abuse Most licensure revocation /suspensions are due to alcohol and drug use.
A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent? 1) Rate 2) Rhythm 3) Amplitude 4) Deficit
3, amplitude Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 +:0 indicating no palpable pulse; 1 + indicating a faint, but detectable pulse; 2 + suggesting a slightly more diminished pulse than normal; 3 + is a normal pulse; and 4 + indicating a bounding pulse.
Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following? 1) Tachycardia 2) Bradycardia 3) Arrhythmia 4) Hypertension
3, arrhythmia Tachycardia is a condition that makes your heart beat more than 100 times per minute. An irregular heart pattern would be considered an arrhythmia or dysrhythmia.
The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is easier. The nurse is engaging in which phase of the nursing process? 1) diagnosing 2) assessment 3) evaluation 4) implementation
3, evaluation Evaluation is reviewing whether implementation were or were not effective.
Before developing a procedure, a nurse reviews all current research-based literature on insertion of a nasogastric tube. What type of nursing will be practiced based on this review? 1) factual based nursing 2) authoritative nursing 3) evidence based nursing 4) institutional practice
3, evidence based nursing
A nurse is preparing a teaching plan for a newly married female client with a cervical (C5) spinal cord injury. The client does not want to become pregnant at this time. What sexuality teaching will be important for the nurse to include? (Select all that apply.) 1) Suggest she ask her spouse to substitute a vibrator in place of intercourse. 2) Provide her husband with a vasectomy referral. 3) Instruct the client's spouse on how to properly insert a diaphragm. 4) Encourage her to be patient and practice a variety of sexual techniques. 5) Provide brochures on adaptations for sexual practice.
3,4 & 5. The C5 cervical injury client will have paralysis of the legs, torso, wrists, and hands. Patience and adaptations for sexuality practices are to be encouraged for the couple because of the cervial injury.This client will not be able to insert any form of contraception by herself. If the couple does not use condoms, it is vital to provide her husband with instruction on insertion of a diaphragm. Providing the couple with literature on sexual practice will help to pave the way for discussion. While the couple does not wish to have children at this time, there is no indication that they never want to have children; therefore, providing a vasectomy referral is not appropriate. Suggesting that the couple suspend intercourse is an intimate decision that they should arrive at on their own, after exploring multiple options. It is premature and inappropriate to advise the use of a vibrator as a substitute for sexual intercourse for this newly married couple.
To reduce urethral irritation, where should the nurse secure the female client's Foley catheter? 1) groin area 2) lower thigh 3) inner thigh 4) lower abdomen
3. inner thigh To reduce urethral irritation and allow drainage, the nurse should tape the Foley catheter to a female client's inner thigh. Taping the catheter also prevents excessive traction against the bladder neck. Taping the catheter to the groin or lower abdomen would not allow for proper drainage and would cause urethral discomfort. Taping the catheter to the lower thigh would pull on the catheter and cause urethral irritation.
The nurse understands that medication absorption is affected by the administration route. Which route for medications has the fastest absorption rate? 1) Cream applied to the skin 2) Subcutaneous injection 3) Intravenous injection 4) Enteric-coated capsules
3. intravenous injection
The nurse is researching if ordering wound care for a client is within the scope of nursing practice. Where should the nurse review the guidelines or law? 1) The American Association of Colleges of Nursing (AACN) guidelines 2) The State Medical Board memorandum 3) State Nurse Practice Act 4) Hospital Protocols
3. state nurse practice act The state's duty to protect those who receive nursing care is the basis for a nursing license. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. Together the NPA and rules/regulations guide and govern nursing practice
A client has been admitted to the acute care unit after surgery to debride an infected skin ulceration. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? 1) Primary Intention 2) Secondary Intention 3) Tertiary Intention 4) Quadratic Intention
3. tertiary intention Tertiary intention (delayed primary closure) occurs when a wound is initially left open after debridement of all nonviable tissue.
how many ml in ounce?
30 ml
The nurse is caring for a critically ill patient. What are the contraindications for administering medications by the oral route for this patient? (Select all that apply.) 1) Penicillin allergy 2) Fractured femur 3) Family visitor 4) Unconsciousness 5) Vomiting
4 & 5. unconsciousness and vomiting
A nurse is educating a client about the benefits of exercise in reducing stress. How often would the nurse recommend the client exercise? 1) Two hours every day 2) One hour once a week 3) 60 to 75 minutes, once a month 4) 30 to 45 minutes, most days of the week
4) 30 to 45 min, most days of the week
A client responds to an approaching diagnostic test with a rapidly beating heart and hands that are shaking. This is the result of what type of response? 1) Defense mechanism 2) Withdrawal behavior 3) Stress adaptation 4) Coping responses
4) coping responses
A patient has a respiratory rate of 24 breaths/minute and is having shortness of breath. What should the nurse do first? 1) Administer 100% oxygen. 2) Obtain an oxygen saturation level. 3) Inform the primary health-care provider of the patient's status. 4) Elevate the head of the patient's bed to a 60-degree angle.
4) elevate the head of the patients bed to a 60 degree angle 1. Although oxygen may be needed, it is premature to administer oxygen without obtaining more data. In addition, administering oxygen will need a health-care provider's order unless it is an emergency situation. 2. Obtaining a pulse oximetry level will provide useful data, but it will not assist in alleviating the patient's symptoms. 3. Elevating the head of the bed should be the first intervention because it is the least invasive, does not require a health-care provider's order, and may alleviate the problem. Raising the head of the bed allows the abdominal organs to drop by gravity, facilitating expansion of the thoracic cavity during inhalation. 4. Notifying the patient's primary health-care provider may be necessary, but it is premature if done beforeadditional data are collected and other interventions are attempted to alleviate the problem. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word first in the stem sets a priority.
A nursing instructor asks the student to explain the concept of health. Which of the following statements made by the student accurately describes this concept? 1) health is always an objective state 2) Health is not determined by the client. 3) Health is an absence of illness. 4) Health is a state of optimal functioning.
4) heals is a state of optimal functioning
While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating? 1) The importance of food in meeting a basic human need 2) A low value on collegiality and friendship 3) Men never gossip 4) Basic respect for human dignity
4, basic respect for human dignity
how many ml in a teaspoon?
5 ml
A patient has a respiratory infection and the primary health-care provider prescribes ciprofloxacin (Cipro) 400 mg IM injection every 8 hours. The vial of ciprofloxacin states that there is 50 mg per mL. How many mL should be obtained to prepare the prescribed IM?
8 mL
Benzodiazepine antidote?
Flumazenil (Romazicon)
opioid antidote
Naloxone (Narcan)
warfarin antidote
Vitamin K
autonomy
a persons right to make their own choices
beneficence
acting for good, the best intensions
battery
actually physically hurting someone
calcium channel blocker antidote
calcium chloride, calcium gluconate
negligence
conduct below the standard of care
nonmaleficence
do no harm
justice
fairness, equal treatment
Insulin antidote
glucagon
fidelity
keeping your promises
Heparin antidote
protamine sulfate
assault
threatening physical harm
