funds exam 3

Which statement made by a patient of a 2-month-old infant requires further education?

"i'm going to alternate formulas with whole milk starting next month."

The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen?

"with the enclosed towelettes, wipe your labia from front to back before collecting the specimen."

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented prior to the test? (select all that apply)

* ask the patient about any allergies and reactions * ensure that informed consent has been obtained

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (select all that apply)

* change in bowel habits * blood in the stool * incomplete emptying of the colon * unexplained abdominal or back pain

Which of the following may cause Clostridium difficile infection? (select all that apply)

* contact with c. difficile bacteria * overuse of antibiotics

Which of the following statements correctly describes the evaluation process?

* evaluation is an ongoing process * evaluation involves making clinical decisions * evaluation requires the use of assessment skills

What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention? (select all that apply)

* keep the bowels regular * wear cotton underwear * cleanse the perineum from front to back

Which nursing action is a part of the evaluation phase of the critical thinking process? Select all that apply.

* looking at all the situations objectively * using several criteria to determine the effectiveness of a nursing intervention

Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (select all that apply)

* to identify and label nurse-sensitive patient outcomes * to test the classification in clinical settings * to define measurement procedures for outcomes

Match the following steps for administering a prepackaged enema with the correct order in which they occur. 1. Insert enema tip gently in the rectum. 2. Help a patient to bathroom when he or she feels the urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient.

6, 4, 3, 1, 5, 2

For a client with difficulty swallowing, the nurse should crush which medication?

acetaminophen extra strength

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?

aspiration pneumonia

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention?

check the medical record to see if there is a medication order for abnormal glucose levels

How can a nurse best evaluate the effectiveness of communication with a client?

client feedback

Which of the following does a nurse perform when discontinuing a plan of care for a patient?

confirms with the patient that expected outcomes and goals have been met

An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially?

dehydration

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention?

evaluating the client's ability to care for the ileostomy

Which step in the nursing process would involve promoting a safe environment for the client?

implementation

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider?

light pink urine

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

measures quality of care within hospitals

The nurse evaluates which laboratory values to assess a patient's potential for wound healing?

nitrogen balance

which is an abnormal finding of the urinary system?

pain in the flank region upon hitting

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?

paralytic ileus

a nurse is preparing to install an enteral feeding to a client with an NG tube in place. which of the following is the nurse's highest assessment priority before performing this procedure?

verify the placement of the tube

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter?

wash with soap and water prior to applying the condom type catheter

A school nurse is asked to develop a program for teachers about infection control, especially focusing on hand washing technique. What is the most effective way for the nurse to evaluate what the teachers have learned?

watch the teachers demonstrate infection control techniques

A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client?

weight gain

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition?

when 75% of the patient's nutritional needs are met by the tube feedings

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply.

"i should drink at least six glasses of water every day." "i can include bran muffins in my breakfast daily." "i will walk every day as part of my exercise regimen."

During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which reply by the nurse is best?

"to prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours."

A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. (select all that apply)

* quality of life * use of clinic services * adherence to use of inhaler

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this?1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses.

3, 4, 2, 1, * reassess the patient, compare assessment findings to validate existing nursing diagnoses, decide if the nursing interventions remain appropriate, modify care plan as needed

A primary health care provider prescribed an indwelling urinary catheter for a client. Which catheter should the nurse use to implement this prescription?

C

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client?

electrolyte imbalances

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort?

engage the patient in the setting mutual outcomes for distance he is able to walk

A client has surgery for an abdominal cholecystectomy and returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first?

ensure that all tubes are attached to collection devices

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?

erythema of skin will be mild to none within 48 hours

What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)?

hang the urinary drainage bag below the level with the bladder

A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. Which type of stool should the nurse expect?

moist and formed

The nurse writes an expected outcome statement in measurable terms. An example is:

patient will report stool soft and formed with each defecation

A patient needs to learn to use a walker. Which domain is required for learning this skill?

psychomotor domain

What should the nurse include in dietary teaching for a client with a colostomy?

the diet should be adjusted to include foods that result in manageable stools

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?

wrong diagnostic label

a nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. when the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse "why the water is necessary." which of the following is an appropriate response by the nurse?

"water helps clear the tube so it doesn't get clogged."

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?

"wear cotton underwear"

Which nursing interventions should the nurse implement when removing an indwelling urinary catheter in an adult patient? (select all that apply)

* allow the balloon to drain into the syringe by gravity * initiate a voiding record/bladder diary

A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? (select all that apply)

* appropriateness of the intervention for the patient * correct application of the intervention for the patient care setting

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (select all that apply)

* assess condition of skin before making the call * explain the patient's response emotionally to the repeated leaking of stool * describe the type of bag being used and how long it lasts before leaking

a nurse is caring for a client in a long term care facility who is receiving Enteral feedings via an NG tube. which of the following is an appropriate nursing action prior to administering the tube feeding? (Select all that apply)

* auscultate bowel sounds * assist the client to an upright position * test the pH of the gastric aspirate

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults?

* avoid grapefruit and grapefruit juice, which impair drug absorption * take a multivitamin that includes Vitamin D for bone health * cheese and eggs are good sources of protein

A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? (select all that apply)

* checked the IV infusion rate * inspected the condition of the IV dressing at the site

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (select all that apply)

* checks scientific literature or policy and procedure * reassess the patient's condition * collects all necessary equipment * considers all possible consequences of the procedure

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (select all that apply)

* data collection * data interpretation

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (select all that apply)

* defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs * helps nurses focus on the scope of nursing practice * builds and expands nursing knowledge

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (select all that apply)

* how does your diabetic diet affect you and your family? * what worries you the most about having diabetes? * what do you believe will help you control your blood sugar?

Which skills must a patient with a new colostomy be taught before discharge from the hospital? (select all that apply)

* how to change the pouch * how to empty the pouch * how to open and close the pouch * how to determine if the ostomy is healing appropriately

a nurse is caring for a client who has had diarrhea for the past 4 days. when assessing the client, the nurse should expect which of the following findings? (select all that apply)

* hypotension * fever * poor skin turgor

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (select all that apply)

* impaired skin integrity related to physical immobility * nausea related to gastric distention

Which are key points that the nurse should include in patient education for a person with complaints of chronic constipation? (select all that apply)

* increase fiber and fluids in the diet * exercise for 30 minutes every day * schedule time to use the toilet at the same time every day

The nurse is organizing a disease prevention program for a specific cultural group. To effectively meet the needs of this group the nurse will: (select all that apply)

* involve those affected by the problem in the planning process * assess commonly held health beliefs among the cultural group * include cultural practices that are relevant to the specific community

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (select all that apply)

* maintaining IV infusion at 100 mL/hr * consulting with dietitian on initial foods to offer patient

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (select all that apply)

* makes it quicker and easier for nurses to intervene * sets a level of clinical excellence for practice * delivers evidence-based interventions for stage II pressure ulcer

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (select all that apply)

* making a judgement of the value of improved adherence for the patient * determining all consequences associated with the patient missing specific medicines

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (select all that apply)

* notion of urgency for nursing action * symptom pattern recognition suggesting a problem * mutually agreed on priorities set with patient

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.

* nursing diagnoses involve the client when possible * nursing diagnoses involve the sorting of health problems within the nursing domain * nursing diagnoses involve clinical judgment about the client's response to health problems

For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (select all that apply)

* patient describes correct schedule for taking antiarthritic medications * patient explains situations for using heat application on inflamed joints

The nurse would delegate which of the following to nursing assistive personnel (NAP)?

* performing glucose monitoring every 6 hours a patient * documenting PO intake on a patient who is on a calorie count for 72 hours

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (select all that apply)

* policy for conducting hourly rounds * staffing level * interruption by staff nurse colleague

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for:

* sepsis * pleural effusion * cardiac arrhythmias

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (select all that apply)

* shows competence in how to monitor patients' clinical status and inform the physician of critical changes * listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly

Which of the following nursing diagnoses is stated correctly? (select all that apply)

* sleep deprivation related to sustained noisy environment * ineffective protection related to inadequate nutrition

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (select all that apply)

* the call to the ostomy and wound care specialist is an indirect care measure * the cleansing of the skin is a direct care measure

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (select all that apply)

* the intervention should be directed at reducing noise * the intervention should be shown to be effective in promoting sleep on the basis of research * the intervention should be one acceptable to the patient

Which patients are at high risk for nutritional deficits?

* the middle-age female with celiac disease who does not follow her gluten-free diet * the 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (select all that apply)

* the nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test * the nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test * the nurse reviews with the NAP, newly hired to the floor, her experience in measuring blood pressure

In which of the following examples are nurses making diagnostic errors? (select all that apply)

* the nurse who observes a patient wincing and holding his left side and gathers no additional assessment data * the nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include?

* the purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids * the fat emulsion will help control hyperglycemia during periods of stress * the parenteral nutrition will help your wounds heal

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (select all that apply)

* using a standardized checklist for essential information * doing pre-work such as checking lab results before giving report * include the wife in the hand-off discussion

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in his right forearm. The IV site is intact, and no complaints of tenderness. I moved (ambulated) him twice during the shift; he tolerated walking to the end of the hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (select all that apply)

* walked to end of hall * no shortness of breath

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (select all that apply)

* when the patient states that he or she is pain free * just before lunch, when the patient is most awake and alert

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step?1. Consider the context of the patient's health problem and select a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label

2, 3, 4, 1 * reviews assessment data, noting objective and subjective clinical information, clusters clinical cues that form a pattern, chooses diagnostic labels, considers the context of the patient's health problem and begins with the first step

Which of the following is the correct order for insertion of an indwelling catheter in a female patient?1. Insert and advance catheter.2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus. 5. Drape the patient with the sterile square and fenestrated drapes. 6. When urine appears advance another 2.5 to 5 cm. 7. Prepare sterile fields and supplies. 8. Gently pull the catheter until resistance is felt. 9. Attach drainage tubing.

5, 7, 2, 4, 1, 6, 3, 8, 9

What is the correct order for an ostomy pouch change? 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1

The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. What is the correct order of steps to perform this procedure? 1. Place a patient in high-Fowler's position. 2. Have a patient flex head toward chest. 3. Assess patient's gag reflex. 4. Determine length of tube to be inserted. 5. Obtain radiological confirmation of tube placement. 6. Check pH of gastric aspirate for verifying placement. 7. Identify a patient with two identifiers.

7, 1, 3, 4, 2, 5, 6

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I moved (ambulated) him twice during the shift; he tolerated walking to the end of the hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention?

IV fluid administration

A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of:

a learning objective

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include?

administering water after the feeding is completed

What is a critical step when inserting an indwelling catheter into a male patient?

advance the catheter to the bifurcation of the drainage and balloon ports

The nurse should do which of the following when placing a bedpan under an immobilized patient?

after positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse:

allows the patient time to express himself/herself and ask questions

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what should the nurse suspect?

an intestinal obstruction

When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, the nurse tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use?

analogy

A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction?

asking patient to identify three low-sodium foods to eat for lunch

Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed?

aspirate for a residual volume

The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention?

assess the catheter and drainage tubing for obvious occlusion

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention?

assess the intake and output

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?

assessment

A client has a surgically created colostomy. What is the most effective nursing intervention initially to help the client accept the colostomy?

begin to teach self-care of the colostomy by introducing equipment

What best describes measurement of post-void residual (PVR)?

bladder scan the patient immediately after voiding

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what?

cause the device to pull away from the skin

The nurse is preparing to administer a nasogastric tube feeding to a client via an infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

checking for residual stomach contents

A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection?

clean the central line port through which the TPN is infusing with alcohol

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?

cognitive

When planning for instruction on cardiac diets to a patient with heart failure, which of the following instructional methods would be the most appropriate for someone identified as a visual/spatial learner?

colored visual diagrams that categorize foods according to fat and sodium content

A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of:

comparing outcome criteria with actual response

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation?

critical thinking

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of:

data cluster

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use?

demonstration

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format?

disturbed sleep pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 1200. What is the appropriate nursing action?

do not reinstall aspirate and hold the feeding until you talk to the primary care provider

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately?

do you dribble urine constantly?

a client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. what is the nurse's initial action?

document assessment

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient?

enhancing patient knowledge about the effects of diabetes

A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of:

evaluative measures

A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation:

examining results of clinical data

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of:

expected outcomes

A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn?

expressing the importance of learned the skill correctly

a client recently has surgery to create an ileostomy. the nurse assesses the client 3 days post-operative for which most frequent complication of this type of surgery?

fluid and electrolyte imbalance

a nurse is talking with a client who reports constipation. when the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

fresh fruit and whole wheat toast

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first?

have the patient perform a Valsalva procedure

The nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver?

have you experienced frequent, small liquid stools recently?

A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. Which type of content is the nurse providing?

health promotion and illness prevention

A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first?

how to use an inhaler during an asthma attack

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement?

identifying the medical diagnosis instead of the patient's response to the diagnosis

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

individualizing how to apply the clinical guideline for a patient

When a patient has fecal incontinence as a result of cognitive impairment, it may be helpful to teach caregivers to do which of the following interventions?

initiate bowel or habit training program to promote continence

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?

institute measures to prevent constipation

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for the last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error?

insufficient number of cues

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error?

interpreting

During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with what problem?

lactose intolerance

There is no urine when a catheter is inserted into a female's urethra. What should the nurse do next?

leave the catheter there and start over with a new catheter

while a nurse is administering a cleansing enema, the client reports abdominal cramping. which of the following is the appropriate intervention?

lower the enema fluid container- slow it down, then stop if it does not get better

A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor?

mother's deficient knowledge

A client has a nasogastric feeding tube inserted, and the healthcare provider prescribes the feeding to be instituted immediately. What should the nurse do first?

obtain an x-ray to verify that the tube is in the stomach

A nurse obtains daily stool specimens for a client with chronic bowel inflammation. What does the nurse determine is the reason these stool examinations were prescribed?

occult blood

The nurse is teaching the patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen?

one fecal smear from three separate bowel movements

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit?

patient

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following?

physical care technique

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention?

placing patient supine while giving a bath

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

planning

The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n):

problem-focused nursing diagnosis

A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report?

projectile vomiting

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient?

provide only the information that the patient needs to go home

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first?

reconnect the drainage tubing

After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following?

reflection-on-action

Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care?

registered nurse

A healthcare provider prescribes intermittent nasogastric tube feedings to supplement a client's oral nutritional intake. Which hazard associated with a nasogastric tube feeding will be reduced if the nurse administers this feeding over 30 to 60 minutes?

regurgitation

After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube to negative pressure. What does the nurse explain is the purpose of this tube?

removing fluids and gas from the upper gastrointestinal tract

What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day?

report the time and amount of first voiding

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?

rise of formula in the tube

The nurse is caring for a patient with an ileostomy. Which intervention is most important?

selecting or cutting a pouch with an appropriate-size stoma opening

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?

sequence of steps used to meet the client's needs

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?

start a scheduled toileting program

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention?

stop feeding her and place on NPO

a nurse is caring for a client who is receiving continuous tube feedings. which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feedings?

stop the feeding

During the administration of a warm tap-water enema, the patient complains of cramping abdominal pain that he rates 6 out of 10. What is the first thing the nurse should do?

stop the instillation

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first?

talking with the patient about her concerns and acknowledging her sense of unfairness

A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation?

telling approach

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care?

the nurse asks, "did you believe that you received the information you needed to follow your diet?"

Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urinary catheter?

tubing luer-lok port

The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care?

urinary tract infection

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen?

urinate small amount, stop flow, fill half of cup