Final Review
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
"Dizziness occurs when you change position and is related to decreased fluid volume in the body."
A client who will undergo radionuclide imaging asks the nurse if she can be sexually active after the procedure. What is the appropriate nursing response?
"Use an effective contraception for the short period, during which radiation continues to be present in your system."
which statement by the nurse best gets client to express their feelings
"you said your back pain hasn't gotten better since surgery, how difficult has it been to adapt to everyday activities?"
the nurse has completed teaching about draining a continent ileostomy, which statement indicates teaching was effective? (select all)
1)"it will take 5-10 minutes for complete emptying" 2)"to help with drainage i will bear down as if having a bowel movement" 3)"I will lower the external end of the catheter at least 12 inches below my stoma"
the nurse is caring for an older client with confusion, who continues to pull at a nasogastric tube despite interventions. what is most appropriate nursing interventions? (select all)
1)contact health care provider to order restraints 2)assess for fluid/electrolyte imbalance 3)arrange for a sitter
A nurse is preparing for a skin care certification course and needs to correctly identify various lesions that may be seen on the skin. Which definitions are correct? Select all that apply.
A. vesicle is an elevated, round lesion filled with serum B. nodule is an elevated solid mass E. papule is an elevated palpable solid mass
A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? Select all that apply.
B. Oxygen saturation is 90%. D. Heart rate is 130 beats per minute. F. Pain is 8 on scale of 1-10 E. temp is 101.4
A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which scale should the nurse use to assess the client's pain?
FACES scale
A 4-year-old client visits the health clinic for a tetanus injection. The client is afraid of needles and is therefore restless and crying. What should the nurse do in order to coax the client to receive the injection?
Hold the client's hand and offer words of encouragement.
The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. Which of the following is the most appropriate response by the nurse to decrease the client's anxiety?
I will start an IV that will add fluids directly to the blood stream
The nurse is preparing to insert a nasogastric tube. Which nursing intervention is appropriate? (Select all that apply.)
Measure from nose to earlobe to xiphoid process, Arrange for abdominal x-ray following tube insertion, Assess client's level of consciousness, Arrange a cue with the client if a pause in inserted is needed.
nurses entering room taking TB precaution, which are requirement for PPE in that room
N95 respirator
A nurse has cleansed the infected wound of a middle-aged client. What is the first step nurses take in the orderly sequence for removing their garments?
Removing the garments that are most contaminated first
A client admitted to the health care facility for minor surgery is given a booklet by the nurse about the health care facility. Which of the following is a purpose of this booklet?
To orient the client to the facility
The nurse is reviewing the following laboratory values with a client. Which of the following values should the nurse provide further education on including educational materials?
Triglyceride 210 mg/dl
The nurse is providing instructions on obtaining a clean catch urine for a female client. Which of the following statements should the nurse include?
after voiding a small amount collect the urine into sterile container
Before inserting a rectal tube, which of the following nursing interventions will the nurse implement?
ambulate the client in the hallway
Which of the following categories of medications will be utilized as adjuvant medications with prescribed analgesics?
antidepressants
which of the following categories of medications will be utilized as adjuvant medications with prescribed analgesics?
antidepressants
nurse caring for a diabetic client with wound, which should nurse do first?
assess wound and skin around wound
a nurse is caring for a client admitted with pneumonia, which of the following is priority?
assessment
The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?
bedside commode
client is admitted with pneumonia how can a nurse assure education needs are full-filled
begin teaching on admission and through out stay
A postsurgical client is recovering in hospital following bowel surgery. The client's family is eager to bring the client some of the client's favorite foods to make the client's stay more pleasant and has asked the nurse whether this practice is acceptable. The client is currently on a clear liquid diet, which will be changed as the client tolerates intake. What food item is currently acceptable within this hospital diet?
black tea
A nurse is conscientious about implementing the principles of asepsis while providing care for clients. The principles of asepsis include which of the following?
blood an body fluids, all non sterile services are equally contaminated
A nurse is caring for a client with excessive abdominal fat. The nurse should inform the client about a risk associated with excessive abdominal fat. What is that risk?
cardiovascular disease
A nurse is performing a physical assessment for a client using the palpation technique. What is one of the purposes of using this technique?
check skin temp and moisture
the nurse is inserting a nasogastric tube, which of the following instructions should the nurse provide when the tube is in the oropharynx?
chin to chest
select all that apply: nurse is preparing to create a plan of care for a client, which of the following components are included in development of the care plan:
client centered, goal directed, evaluation of goals, prioritize goals
when keeping a clients personal belongings in the locker room the nurse should assure it is signed by which of the following people?
client supervisor
select all: when documenting plan of care for a client which of the following should the nurse include in documenting
client teaching, subjective and objective data, clients care needs, safety precautions implemented prior to leaving the room
Place the steps in the correct order for inserting a Foley catheter:
close door and pull curtian, raise bed up to high position, remove wrapper from kit, remove and apply sterile gloves, open and pour packet of antiseptic solution and lubricate catheter, pick up moistened cotton ball and wipe labia, insert tip of catheter until urine flows, advance another 0.5-1 in, instill sterile water and inflate balloon
A nurse is caring for a client who has undergone a surgical intervention in which the pain pathways in the spinal cord have been interrupted to control pain in his back. The nurse knows that the client has undergone which treatment?
cordotomy
The nurse is caring for a client who reports urinary incontinence over the past 2 months. In reviewing the electronic health record, which new prescriptions will the nurse look for that may be related to the concern? (Select all that apply.)
diuretics, antidepressants, sleeping pills
the nurse is caring for a client with urinary incontinence, when reviewing health record which meds should nurse look for?
diuretics, antidepressants, sleeping pills, antihypertensives
A nurse is caring for a client who is experiencing dumping syndrome following a nasointestinal intubation. Which symptom is seen in a client with dumping syndrome?
dizziness
A health care facility has experienced a recent outbreak of infection that is attributable to an antibiotic-resistant microorganism. Which type of client is most likely at increased risk for infection?
elderly
A hospital client went five days without having a bowel movement despite maintaining adequate food and fluid intake. The nurse obtained an order for hypotonic cleansing enemas as needed and has administered two in succession, each with good effect. The nurse would monitor the client for?
electrolyte embalance
The nurse is administering prescribed medicine to a client for diarrhea. The nurse provides education to the client about which of the following factors that can lead to diarrhea? Select All That Apply
emotional stress, laxative abuse, and bowel disorders
nurse plans interventions for anxiety which are appropriate interventions (select all)
encourage client to identify what is causing perceived anxiety, have client listen to relaxation tape, provide education on reducing dietary intake of caffeine
a nurse is caring for a terminally ill client whose death is intemment, and has developed a close relationship with the family, which of the following is most appropriate intervention?
encourage family discussion of feelings
a client admitted to the health care facility is assessed using the minimum data set, how often is MDS repeated for the client?
every three months
nurse is providing education to client with heart disease what should the nurse do first?
find out what they know about their disease
nurse is creating a teaching plan for a client which of the following is important to include in the assessment process (Select all)
find out what they want to know, establish what they should know to remain health, determine their learning style
A nurse is caring for a 65-year-old male client who is postoperative day 1 following a total hip replacement. Which should the nurse use in order to assist the client to eliminate urine?
fracture pan
A nurse is assessing the volume of liquid nutrition that has been tube-fed to a client. Which of the following complications should the nurse monitor for?
gastric reflux
A nurse is administering prescribed tuberculosis (TB) drugs to a client whose infection is attributable to a drug-resistant strain of the disease. What other infectious disease has developed drug-resistant strains?
gonorrhea
a nurse is giving TB drugs, what other infectious disease has developed drug resistance?
gonorrhea
which of the following is priority intervention when entering clients room?
hand hygiene
after standard precaution the nurse starts cleaning an infected wound, which standard precautions should nurse select or complete
hand hygiene and gloves
nurse taking vital signs of client with acute diarrhea, what is highest priority the nurse must perform before leaving the clients room?
hand washing
which of the following should be included in education about Hep A
hand washing is prevention, low grade fever is sign that may develop
A client with multiple pressure ulcers requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
high protein
a client with multiple pressure ulcers requires a feeding tube, which type of formula does the nurse anticipate will be ordered?
high protien
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
hypertonic saline
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
immediatly
which is priority when transferring client to another room or facility?
inform the family
A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction?
insert lubricated gloved finger into rectum
a nurse is changing bed linen for a client having a surgical repair of a hernia, which precautions should nurse follow
just standard percautions
A nurse notes that the volume of the client's urinary elimination is less than 300 mL/day. What could be the possible cause for the low volume of urination by the client?
kidney dysfunction
the nurse has explained therapeutic communication to the client, which follow up actions should the nurse do?>
listen to comments from client about their nutrition
the nurse is discharging a client who is anxious about going home, the nurse should implement the following interventions
maintain calm manner, establish trust with client, follow consistent schedules, teach relaxation techniques
when maintaining medical records for a client, the nurse knows it is a legal issue, what should the nurse do for legal defensible charting?
make sure their name is on all pages
A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?
my favorite drink is coffee with sugar
the nurse is reviewing quality improvement reports, which of the following about neonatal mortality rates is true?
number of neonatal deaths per 1000 live births
which of the following can a nurse delegate to an unlicensed personnel?
obtain supplies, obtain base vitals, orient client to room and call light
Which clients, at risk for poor nutritional intake, and would benefit from nutritional counseling from the nurse? (Select all that apply.)
older adults on fixed incomes, pregnant teens, people with substance abuse problems
A nurse is caring for a constipated client who has abdominal distention. What other signs and symptoms should the nurse monitor the client for?
oozing liquid stool
A client presents to the Emergency Department with a temperature of 100.6F and BP of 108/60 mm Hg. What intervention does the nurse anticipate providing?
oral fluids
A nurse is caring for a client with pseudoconstipation. The nurse educates the client about the which of the following causes of pseudoconstipation?
overuse of suppositories
which nursing assessment finding is priority?
pain
when sterilizing the endoscope used for a client, which of the following should be used?
peracetic acid
the client has been receiving care in a facility for several days under droplet precautions, how can the nurse best minimize psychological effects of the clients illness?
plan frequent interactions with the client
a nurse is evaluating clients ability to change dressing before discharge, the nurse notices he does not do it correctly, which is the most appropriate action?
praise client on what they did well and explain what they need to work on
A nurse notes that vomiting occurs with great force in a client with gastrointestinal bleeding. How should the nurse document this condition?
projectile vomiting
a clients preparing to be discharged home after admission to cardiac unit following myocardial infarction, which should the nurse do as priority?
provide client with education about activity and medication
A client with a nasogastric tube to suction for decompression reports " I am thirsty." Which of the following is an appropriate intervention?
provide ice chips
A nurse is caring for a client with subnormal temperature. Which actions should the nurse perform to provide heat to the client's internal organs?
provide warm fluids
A nurse is educating a client on how to irrigate his colostomy. The nurse informs the client that the colostomy should be irrigated in order to:
regulate the timing of the bowel movements
nurse cleansed infected wound of client, what is the first step in order to removing the garments
remove garments that are most contaminated first
after collecting all data the physician writes R/O in medical records, what does the physician mean?
rule out
A nurse is assessing the lung sounds of a client with respiratory disorders. What is a normal bronchial sound?
shorter on inspiration than expiration with a pause between
an elderly client with a tracheotomy is to be discharged, which facility should the nurse suggest for continued care until complete recovery?
skilled nursing facility
A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope?
slightly below left nipple
nurse receives client with small pox, which of the following infection control should nurse implement?
standard, contact, and airborne precautions
A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?
take before 6 p.m at night
A nurse is caring for a client who is to undergo a rectal examination. What should the nurse administer to cleanse the bowel in preparation?
tap water and normal saline solution
community health nurse providing care to diabetic with foot ulcer, which should be done for intervention
teach client education on applying medicine to their wound
A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?
tell me more
results reveal a patient has been colonized, what are the implementations of that finding?
the microorganism is present in that client but the client shows no symptoms
A client has been swabbed for an antibiotic-resistant microorganism upon admission to the hospital and the results reveal that she has been colonized. What are the implications of this assessment finding?
the microorganism is present on the client but it is not making them sick
a client reports to the primary care facility with complaints of chest pain, after investigating the client anxiously inquired he had a heart attack, how should the nurse reply?
the physician wants to monitor you can control your pain
A client has been given Cologuard testing supplies. What teaching will the nurse provide about the purpose for this test?
this test detects mutant DNA from tumor cells present in stool
nurse is helping another nurse put on a gown before helping another nurse with a dressing change, which of the following advantages does cover gown offer?
tight fitting wrist bands help avoid contaminating the forearm
a nurse caring for a client in a healthcare facility has to maintain a medical record for a client, which of the following is a use for a medical record?
to investigate quality care of insurance
a nurse is caring for a client with lower back pain due to contracted muscles, which type of splint should the nurse provide
traction splint
When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? (Select all that apply.)
triglyceride, cholesterol, and lipoprotein
A nurse is administering prescribed medication through an intestinal decompression tube to a client with a complete bowel obstruction. Which is a feature of the tube used for intestinal decompression?
tube is weighted with tungsten
How many times should a nurse administer medication that is BID?
twice a day
A nurse is caring for a client with a history of cardiac and vascular disease. Which fats should the nurse allow in the client's diet for his condition?
unsaturated fats
a nurse is informing a nursing student about guidelines from the CDC on hand asepsis,which is correct
wash when visibly soiled