Midterm 3

A nurse is conducting a health history and asks the client about use of complementary and alternative medicine (CAM) to treat her chronic headaches. Which response would require further questions?

"I take herbs to treat my headaches."

A nurse is attending a job fair at the local community center and stops at a booth that is demonstrating technology for client care. While touring the booth, the nurse meets an informatics nurse specialist (INS). Being unfamiliar with this position, the nurse asks the INS, "How did you get this position?" Which response by the nurse would be most appropriate?

"I've had graduate-level education focusing on informatics."

A client is very anxious and states, "I am so stressed." What is the reason stress affects the client's safety?

Stress tends to narrow the attention span

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include?

"Flush the tube before and after each medication."

A client has been diagnosed with diabetes and requests information about complementary therapies that could do along with the prescribed treatment plan. What would be the nurse's best response to this client?

"Healing is slow in complementary therapy, it involves the whole person, and care is individualized. "

In order to prevent the possibility of venous stasis, a nurse is educating a surgical client on how to perform leg exercises. Which statement by the client indicates a sound understanding of leg exercises?

"I'll practice these now and try to start them as soon as I can after my surgery."

The home health nurse is admitting a client to the service for complications related to multiple sclerosis (MS) and the client asks the nurse to explain the use of complimentary health approaches. The client states, "All of the medication I am taking is making me sicker. There has to be a better way." What is the best response by the nurse?

"We can discuss with your health care provider some helpful complimentary therapies."

An informatics nurse is working as part of a team considering an update to a clinical information system already in place. Which questions would be important for the team to ask first? Select all that apply.

"What is the purpose of the change?" "Will it improve overall usability?" "How will its use be incorporated into the nurse's current workflow?"

A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia?

"You will be awake and will not have sensation of the procedure."

The physician's admitting orders indicate that the client is to be placed in Fowler position. Upon positioning this client, how much will the nurse elevate the head of the bed?

45 to 60 degrees

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing?

Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

The alert and oriented client has just been notified of a terminal cancer diagnosis and the need for surgery to extend life. The client tells the nurse, "I am leaving. I am not having the surgery." The client refuses to wait and talk to the primary care provider. What is an appropriate action by the nurse?

Ask the client to sign a form that the client is being discharged against medical advice.

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which major task does the nurse perform immediately during the preoperative period?

Conduct a nursing assessment.

The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client?

Constipation

An informatics nurse specialist is working with a team who is developing an expanded system for documenting critical values in the electronic health record (EHR) being used at the facility. The team has identified the need for this addition and provided appropriate evidence to support this change. The team would now proceed to which phase in the system development lifecycle?

Design and build

The client has an infected nonhealing wound in which negative-pressure wound therapy (NPWT) has been applied. What actions would the nurse employ for this client? Select all that apply.

Empty or replace the canister on the machine when full or nearly full. Measure and record the amount of drainage each shift. Assess for a problem if the machine alarms.

The older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What actions will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply.

Ensure the aquathermia unit contains water to the appropriate level. Assess the client's skin prior to application of heat.

The client has a wound on the ankle that the nurse has cleansed and dressed. The nurse now needs to apply a conforming bandage to keep the dressing in place. What technique will the nurse use to apply the bandage?

Figure-of-eight turn

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients?

Force fluids for an adult client who has a urine output of less than 30 mL per hour.

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's

A nurse is using a technique that involves the five senses to visualize recovering from an upcoming surgical procedure. What type of technique is the nurse teaching the client to use?

Guided imagery

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request?

Inform the physician that it is his responsibility to obtain the signature.

A nurse is researching a standardized herbal supplement to help a client with pain. What does the word standardized mean?

It contains a certain amount of an active ingredient.

A nurse is practicing imagery to relieve stress. What might accompany the imagery to even further promote relaxation?

Listening to music

Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls?

Lock wheels on beds and wheelchairs.

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change?

Nothing; this is a good diet.

The nurse is providing care to an older adult client. Which interventions will the nurse perform to protect the client's skin? Select all that apply.

Offer fluids every hour while the client is awake. Minimize the use of any tape to the skin. Apply moisturizing lotion to feet and hands daily. Wash the perineal area every day.

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall?

Orient the client to the room and environment upon admission.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following?

Paralysis of the legs

Which essential oil can be used during aromatherapy to treat nausea?

Peppermint

An informatics nurse is part of a team that is testing a new electronic health record system. The testing involves large groups of health care providers who will be using the system. During this testing, the system stalls and fails to respond when large numbers of providers are using the system at the same time. Which phase of testing is being conducted?

Performance

An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse?

Report suspicions about the abuse to proper authorities.

Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for Suffocation

A nurse practices holistic client care. Which of the following is a guiding principle of this practice?

The body is a unified, dynamic whole.

The nurse reviews information about defecation with a group of nursing students in preconference prior to their clinical experience for the day. What response by the students indicate that the information given by the nurse is understood?

The center in the medulla and another center in the spinal cord govern the reflex to defecate. This is why brain and spinal cord injuries may need Digital Stimulation to start the bowel movement.

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply.

The client who is experiencing an allergic reaction and is scratching the skin The client who is emaciated from self-induced vomiting and food deprivation The client who has a body mass index (BMI) of 34 The client who has a temperature of 40° C and is perspiring

The nurse is working with a group of clients. Which of the following clients are at risk for a skin alteration? Select all that apply.

The client who is newly diagnosed as having diabetes and requires management education of the disease The client who has experienced vomiting and diarrhea for several days with a loss of 12 pounds in weight The client who is a roofer and spends a lot of time outdoors participating in sports The client who has paralysis and is unable to move in bed, and the nurse provides turning every 2 hours

Which philosophy underlies the use of CAM?

The mind, body, and spirit function as a unified whole.

A nurse is reading a journal article about nursing informatics in which the article describes the two types of nurse informaticists. The nurse demonstrates understanding of the article by identifying which characteristic as being solely reflective of an informatics nurse (IN)?

The nurse has received primarily on-the-job training.

A nurse practitioner uses integrative care in his practice. What does this mean?

The nurse uses both allopathic medicine and CAM.

While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. The nurse is teaching the mother about infant care. What are characteristics of the stool the nurse would expect to assess and teach the mother in breast-fed infants

The stool will be yellow to golden and loose.

The client lives in a remote area and has been referred to a specialist who travels to the area once a month. The client's condition requires an appointment as soon as possible. The low-income client has no reliable transportation. What would the nurse do to facilitate access to the specialist for the client?

Use videoconferencing to access the specialist.

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

an increase in the client's blood pressure

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for:

cardiac problems.

A client with terminal cancer is taking high doses of a narcotic for pain. The nurse will teach the client or family about which common side effect of opioids?

constipation

Which intervention is of major importance during preoperative education?

encouraging the client to identify and verbalize fears

Which consideration should a nurse prioritize relating to the use of herbs and supplements by a client?

potential interactions with drugs

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

serosanguineous

Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly?

soft, watery

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

Transparent film

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

"Always test the temperature of bath water before stepping in."

Which of the following people has the greatest risk for accidental injury?

A worker who operates industrial machines

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

thorough hand hygiene

The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will now perform. Use all options. A. Don clean gloves. B. Empty the JP's contents into a graduated collection container. C. Compress the chamber and replace the JP cap. D. Note the amount of output as well as color. E. Remove gloves and sanitize or wash hands.

A, B, C, D, E

Which nursing intervention occurs in the postoperative phase of the surgical experience?

Airway/oxygen therapy/pulse oximetry

A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus?

Alcohol consumption and smoking

An informatics nurse is assisting with the development of a new clinical information system that will be implemented in the facility. As part of the process, the team is evaluating the purpose of the system and the technological options available. The team is in which phase of the system development lifecycle?

Analyze and plan

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, which postoperative intervention would be included on the plan of care?

Monitor respirations and breath sounds.

A nurse is taking care of a client during the immediate postoperative period. Which duty performed during the immediate postoperative period is most important?

Monitor the client for complications.

What are functions of the skin? Select all that apply.

Sensation Immunologic Protection Temperature regulation

A nurse who is a traditional Chinese medicine practitioner is providing home care to a client who also uses traditional Chinese medicine for health care. What specific assessments would the nurse make?

Tongue and pulses

A trained nurse uses the technique of "Rolfing" to break up tension in client body structures. What type of CAM is being used by this nurse?

Therapeutic massage

A facility is planning to implement an update to the electronic health record. This update is designed to facilitate documentation of critical changes in clients' condition to save time that nurses spend when documenting these changes. An informatics nurse specialist asks a group of staff nurses to test this update to determine if it is working as it was designed. The nurses are involved in which type of testing?

User acceptance

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides . The nurse informs the group that back stress and injury can be prevented by:

spreading the feet shoulder-width apart to broaden the base of support.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the client's body weight