Foundation exam final 2

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision (splint the incision mean placing a pillow over the abdomen to help support the area with the incision). What is the nurse's next step in implementing the plan of care? a. Reassess the client to determine the effectiveness of the interventions b. Instruct the client that pain medication is available at regular intervals. c. Perform additional non-pharmacological pain interventions. d. Notify the physician that the client has required pain medications

A

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? a. Ask a skilled nurse to assist with the procedure. b. Ask the client how the bag is changed. c. Determine the necessity of the bag change. d. Ask the family to assist with changing the bag.

A

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? a. Investigate the circumstances that contributed to client falls b. Determine if client falls have increased on other units in the hospital. c. Reprimand the nursing personnel responsible for the clients when the falls occurred. d. Institute a new policy on the prevention of client falls on the unit.

A

A nurse suspects that the client with Diabetes does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? a. Ask the client to verbalize the medication regimen and diet modifications required. b. Ask the endocrinologist to explain the treatment plan to the client and family again. c. Refer the client to available community resources and support groups. d. Ask the nutritionist to give the client strict meal plans to follow

A

The nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? a. Determine whether the prescribed treatment was effective. b. Check the client's skin turgor. c. Formulate a plan of care based on risk for dehydration. d. Administer an additional liter of intravenous fluids.

A

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? a. A 45-year old with burns to the upper arms and chest and soot on the face who is restless and anxious b. A 68-year old with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning. c. An 18-year old sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who talking on a cell phone. d. A 4-year old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly.

A

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview? a. Administer prescribed pain medication prior to conducting the interview. b. Document that the client refused the interview. c. Use the information that is on the electronic health record and eliminate the need for the interview. d. Inform the client that the interview must proceed before getting anything that will alter perception.

A

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? a. risk for unstable blood glucose b. diabetes c. appendicitis d. hypertension

A

The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured below, what is the highest prioritized nursing diagnosis? a. Decreased Cardiac Output b. Deficient Knowledge c. Anxiety d. Risk for Bleeding

A

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply. a. The client verbalizes understanding of the instructions. b. The client is able to answer the nurse's questions. c. The client asks the nurse to repeat the instructions. d. The client discusses the specifics of what was taught during the session e. The client tells the nurse that the client's spouse will handle the care

A, B, D

Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply a. The nurse identifies that a client's pain is not being adequately treated. b. The nurse determines the client did not lose the expected 2 pounds (0.90kg). c. The nurse sets an anxiety level of 3 or less with the client. d. The nurse documents the client's response to suctioning. e.The nurse performs tracheostomy care using sterile technique

A, B, D

Which are examples of objective data? Select all that apply. a. Laboratory test results b. A client's report of being unable to breathe c. A client's report of pain d. Breath sounds on auscultation e. A client's temperature

A, D, E

A nurse documents the following in the client chart: client's lungs are clear to auscultation. This is an example of what aspect of client care? a. Nursing assessment b. Nursing plan c. Nursing evaluation d. Nursing diagnosis

A. Nursing assessment

Match the order of the nursing process-ADPIE Assessment Nursing diagnosis Planning Intervention evaluation

Assessment Nursing diagnosis Planning Intervention evaluation

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes the goal of increasing oral intake. Why would the priority reason be for the nurse reviewing the plan of care for this client? a. To be sure the interventions are individualized b. To be sure the planned interventions are safe c. To be sure the interventions are evidence-based d. To be sure interventions follow hospital policy

B

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? a. Continue to follow the written plan of care b. Make recommendations for revising the plan of care c. Ask another health care professional to design a plan of care d. State "goal will be met at a later date.

B

After completing an assessment of a client, which data would the nurse determine is the priority for care? a. Lack of family and social support b. Severe bleeding from a wound c. Type 1 Diabetes controlled by insulin d. History of asthma and lung disease

B

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing? a. head to toe assessment b. focused assessment c. general assessment d. time-lapsed assessment

B

Which is the primary reason for a nurse collecting data continuously on a client? a. Most facilities require it for reimbursement. b. The client's health status can change quickly c. It gives the nurse more information to document on the client. d. It makes the client feel as if the nurse is spending more time with the client.

B

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? a. Ineffective Thermoregulation b. Altered Gas Exchange c. Interrupted Breastfeeding d. Impaired Parenting

B

A client has made no progress toward meeting any of the goals for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse best respond to this situation? a. Discontinue the plan of care and recommend the client be discharged b. Replace the nursing plan of care with a plan written by the physical therapist c. Modify the plan of care to reflect the client's current functional ability d. Continue the current plan of care

C

A client in the last stages of lung cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? a. Research other treatment options available for the client b. Remind the client that positive thoughts are essential for recovery. c. Collaborate with other disciplines to plan end-of-life care for the client d. Ask if the client would like to speak with a spiritual adviser

C

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? a. assess the client's activity level b. assess the client's medication regimen c. assess the client's blood pressure d. assess the client's ability to care for self

C

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an over-distended bladder. the client expresses being nervous and informs the nurse that this is the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis related to this client's concerns? a. over distention b. compromised c. anxiety d. physical immobility

C

During the planning phase of the nursing process, a client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? a. Discuss the client's refusal with hospital risk managers. b. Discuss the risks and benefits of a blood transfusion with the client. c. Discuss possible alternatives to a blood transfusion with the physician. d. Discuss the client's options with other church members.

C

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? a. Explain to the client the benefits of ambulation. b.Emphasize to the client the importance of following the treatment plan. c. Medicate the client and wait 30 minutes to ambulate d. Ambulate the client and medicate after ambulation.

C

Which example of client care is not the responsibility of the nurse? a. Monitoring for changes in health status b. Promoting safety and preventing harm; detecting and controlling risks c. Confirming a medical diagnosis d. Tailoring treatment and medication regimens for each individual

C

Which outcome (goal) is correctly written? a. The abdominal incision will show no signs of infection b. The client will tolerate sitting up in the chair c. The client will verbalize five symptoms of infection within three days d. The nurse will change the abdominal dressing once daily

C

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed? a. Ineffective Airway Clearance related to bed rest. b. Immobility related to confinement of bed c. Risk for Impaired Skin Integrity related to bed rest. d. Potential for Pneumonia related to bed rest.

C

A nursing diagnosis is written as Disturbed Body Image related to scar on the left side of the face. What does the phrase "Disturbed Body Image" identify? a. the major defining characteristic of health problem b. the cue to determining a health problem c. The health state or problem of the client d. The expected outcome of the plan of care

C. The health state or problem of the client

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? a. Contact the client's health care provider. b. Document the data for future reference. c. Continue to collect assessment data. d. Consult with a more experienced nurse

D

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? a. Obtaining written consent for the diagnostic procedure b. Posting the sign "NPO after midnight" over the bed c. Adding the diagnosis "Altered Nutrition, Less Than Required" d. Updating the diet orders in the client's plan of care

D

A nurse has just received report and is ready to begin the day. The priority client is still sleeping. What action should the nurse take next? a. Revise the plan of care to add Ineffective Sleep Patterns b. Allow the client sleep until later in the morning c. See your other client's first and save this client's assessment for last d. Awake the client and explain that you need to do an assessment

D

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? a. Child Abuse related to unsafe home environment. b. High Risk for Injury related to impaired home management. c. High Risk for Injury related to abusive parents d. High Risk for Injury related to unsafe home environment

D

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome? a. Ask family members how much trouble the client is having with injections. b. Ask the client to verbally repeat the steps of the injection. c. Ask the client how comfortable the client is with injections. d. Ask the client to demonstrate self-injection of insulin

D

A nurse is educating a newly diagnosed diabetic on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn? a. previous knowledge b. preparation c. intelligence d. anxiety

D

A police officer has come into the ED and requested that you (the nurse) draw blood for a client. Your hospital policy states that before blood can be drawn the client needs to be a)under arrest or b)have a warrant out for their arrest. The police officer states that client is not under arrest and there is no warrant but that they absolutely must have the blood drawn. What is the nurse's action? a. Draw the blood immediately because the police officer out ranks the nurse. b. Ask your nursing supervisor to draw the blood since she will have the authority to do so. c. Ask another nurse to draw the blood. d. Remind the police officer that you cannot draw the client's blood unless the client is under arrest or if the police officer has a warrant.

D

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a. Instruct the client's family to assist the client to ambulate to the bathroom. b. Consult with the physical therapist to determine the client's ability. c. Continue assisting the client to the bathroom to ensure the client's safety. d. Revise the care plan to allow the client to ambulate to the bathroom independently.

D

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? a. Consult with the physician for additional pain medication. b. Assist the client to reposition and splint the incision. c. Discuss the frequency of pain medication administration with the client. d. Assess the client to determine the cause of the pain.

D

QSEN is a project aimed at preparing future nurses to continually improve which aspects of the health care systems within which they work? a. Salary and benefits b. Qualitative research and Quantitative research c. Staffing and numbers of licensed personnel. d. Quality and Safety

D

The nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next? a. Wait and see whether the pain subsides. b. Chart the information. c. Call the family. d. Consult with another nurse.

D

Which nursing action reflects evaluation? a. The nurse measures urine output following administration of diuretic. b. The nurse auscultates the client's lungs and abdomen. c. The nurse sets a tolerable pain rating with the client. d. The nurse identifies that the client does not tolerate activity.

a. The nurse measures urine output following administration of diuretic.

The nurse is developing goals for a client who has been admitted for newly diagnosed diabetes. What goal written by the nurse requires revision? a. By 10/23, the client will state three ways to low blood sugar b. The client will understand how to use the glucometer machine. c. By 10/23, the client will state when to notify the health care provider after discharge. d. By 10/23, the client will demonstrate correct use of the glucometer machine.

b. The client will understand how to use the glucometer machine

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? a. assessment b. clinical reasoning c. caring d. reflection

b. clinical reasoning

A client with hypertension being seen for follow-up care has a blood pressure of 170/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the past 2 weeks. What is the nurse's most appropriate action? a. Inform the client that the blood pressure medication will have to be changed. b. Interview the family to determine if the client is giving accurate information. c. Report the findings to the physician for further plans. d. Reinforce the instructions for the treatment regimen to the client.

c

A client has been admitted to your unit with shortness of breath. The 02 saturation is 90% on 2L via nasal cannula. What would be the most priority nursing diagnosis for the nurse to use to address this client's problem? a. Risk for falls related to inadequate ventilation b. Impaired Verbal Communication related to shortness of breath c. Ineffective Breathing Pattern related to inadequate ventilation d. Self-Care Deficit related to shortness of breath

c. Ineffective Breathing Pattern related to inadequate ventilation

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? a. diagnosis b. evaluating c. planning d. implementing

c. planning

Which outcomes should the nurse recognize as being the most appropriate for a client with a nursing diagnosis of Risk for Infection? a. the client takes the client's own temperature daily b. the client understands what symptoms to monitor for c. the client has a normal temperature and no sign or symptom of infection d. the client takes a prescribed antibiotic

c. the client has a normal temperature and no sign or symptom of infection

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? a. Client tries using relaxation as a means to cope. b. Client will list positive coping strategies and use them. c. Client will learn to cope more effectively. d. Client will identify one coping strategy to try by end of week.

d. Client will identify one coping strategy to try by end of week.

A client has been admitted to the hospital for the treatment of pneumonia. Which statement constitutes a long-term outcome for this client? a. The client will demonstrate the correct use of the incentive spirometer b. The client will ambulate 100 feet without supplementary oxygen or mobility aids. c. The client will express an understanding of strategies for managing fatigue and shortness of breath d. The client will return home able to conduct activities of daily living (ADL's) without experiencing shortness of breath

d. The client will return home able to conduct activities of daily living (ADL's) without experiencing shortness of breath