ICU final

A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?1.Performing a procedure without consent2.Threatening to give a client a medication3.Telling the client that he or she cannot leave the hospital4.Observing care provided to the client without the client's permission

4.Observing care provided to the client without the client's permission

The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1.Semi-Fowler's2.Trendelenburg's3.Reverse Trendelenburg's4.Flat

semifowlers

The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? Vomiting 2.Bulging anterior fontanel 3.Increasing head circumference 4.Complaints of a frontal headache

vomiting

The nurse instructs a client about a low-fat diet. Which menu selection indicates that the client understands the nurse's instructions?

Turkey breast, boiled rice, and fruit

The nurse is preparing to care for a client post LP. whats the best position post procedure

prone with pillow under abdomen

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?1. A client scheduled for a chest x-ray.2. A client requiring daily dressing changes.3. A postoperative client preparing for discharge.4. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift.

.4. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift. ABCs

The nurse employed in a mental health facility is greeted by a neighbor in a local grocery store. Neighbor asks how carol is doing, what's the appropriate response? 1. I cannot discuss any client situation with you 2. if you want to know about carol you will have to ask her yourself 3. being her friend you know that she is having a difficult time and deserves her privacy

1. I cannot discuss any client situation with you gives a reason, isn't disrespectful

the nurse is caring for a client after a craniotomy and monitors the client for IICP. whats an early sign? 1. confusion 2. bradycardia 3. sluggish pupils 4. widening pulse pressure

1. confusion

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? 1. Maintain the client in a flat position. 2. Restrict fluid intake for a period of 2 hours. 3. Assess the client's ability to void and move the extremities. 4. Inspect the puncture site for swelling, redness, and drainage.

2. restrict fluid intake for a period of 2 hours liberal intake to increase CSF

The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?1. A client requiring colostomy irrigation.2. A client receiving continuous tube feedings.3. A client who requires urine specimen collections.4. A client with difficulty swallowing food and fluids.

3. A client who requires urine specimen collections. cuz no assessment needed

The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first?1. A client who is ambulatory.2. A client scheduled for physical therapy at 1 pm3. A client with a fever who is diaphoretic and restless.4. A postoperative client who has just received pain medication.

3. A client with a fever who is diaphoretic and restless acute, ABCs

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?1. A negative Kernig's sign2. Absence of nuchal rigidity3. A positive Brudzinski's sign4. A Glasgow Coma Scale score of 15

3. A positive Brudzinski's sign

The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse?1. The client who requires a bed bath.2. An older client requiring frequent ambulation.3. A client who requires a 24-hour urine collection.4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours.

4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours. cuz LVN can do minor procedure

A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?1. A client complaining of muscle aches, a headache, and malaise.2. A client who twisted her ankle when she fell while rollerblading.3. A client with a minor laceration on the index finger sustained when cutting an eggplant.4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by:1. Documenting a late entry into the client's record.2. Trying to erase the error for space to write in the correct data.3. Using white-out to delete the error to write in the correct data.4. Drawing one line through the error, initialing and dating the line, then documenting the correct information.

4. Drawing one line through the error, initialing and dating the line, then documenting the correct information. 5. document correct info and provide signature

the nurse is caring for a client with a diagnosis of right hemispheric stroke. client is ao4. based on assessment findings, whats the interpretation? 1. had a mild stroke 2. most likely suffered a TIA 3. may have difficulties with language abilities only 4. is likely to have spatial and perceptual disabilities

4. is likely to have spatial and perceptual disabilities

The health care provider has prescribed a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the tray to be sure that which has occurred?

All food items are liquid at body temperature.

A client with heart disease is provided instructions regarding a low-fat diet. The nurse should determine that the client understands the diet if the client states that which food item should be avoided?

Avocados

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet?

Broth, Coffee, Gelatin. A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea.

In planning a low-sodium diet for a client who has recently been diagnosed with heart failure, the nurse should offer the client which food item?

Chicken breast

The nurse is providing instructions to a client with kidney disease about a low-protein diet. The client demonstrates understanding of the dietary instructions by stating the need to limit which food in the diet?

Chicken has high protein

The nurse is evaluating a client's ability to select food items for a low-potassium diet. Which food item, if selected by the client, would indicate an understanding of this diet?

Cranberry juice

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

Cream of wheat, blueberries, coffee. kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids,

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?

Custard. Full liquid food items include: plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices.

The nurse has instructed a client in the foods that are best to consume on a low-fat diet. The nurse determines that the client understands this diet if the client indicates which food item is lowest in fat?

Dry toast and strawberry jelly

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list?

Margarine Cream cheese Luncheon meats

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

Smoked Sausage

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?

Summer squash