NURS 3209 Holistic Nursing - Exam 1
Which term describes foreign particles that enter a host and stimulate the body's immune response? Antibody Macrophage Phagocyte Antigen
Antigen
Which are examples of subjective data? Select all that apply. Anxiety Light-headedness Nausea Edema Laceration
Anxiety Light-headedness Nausea
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? Assist the client to reposition and splint the incision. Consult with the health care provider for additional pain medication. Discuss the frequency of pain medication administration with the client. Assess the client to determine the cause of the pain.
Assess the client to determine the cause of the pain.
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding? This is a normal respiratory rate. Bradypnea is a response to IICP. IICP most commonly results in tachypnea. Bradypnea is uncommon in a client with IICP.
Bradypnea is a response to IICP.
Which type of health problem requires both health care provider- and nurse-prescribed actions to address? Collaborative health problem Health care provider-developed problem Independent health problem Interdisciplinary health problem
Collaborative health problem
What verbs should the nurse use to write outcomes that are measurable? Select all that apply. Hear Feel Know Define Verbalize
Define Verbalize
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? How can I supervise the completion of this task? Does this task fall within the scope of a UAP? What is the client's condition? How can I explain the task to the UAP?
Does this task fall within the scope of a UAP?
Who is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment? Florence Nightingale Sister Callista Roy Dorothea Orem Lydia Hall
Florence Nightingale
The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? Actual nursing diagnosis Syndrome nursing diagnosis Health promotion nursing diagnosis Risk nursing diagnosis
Health promotion nursing diagnosis
The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value? Objective Secondary Primary Subjective
Objective
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? The severity of the client's disease Medications used to treat diabetes mellitus Risk factors for and prevention of diabetes mellitus The cellular metabolism of glucose
Risk factors for and prevention of diabetes mellitus
A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? Follow institutional guidelines. Set priorities using client care standards. Consult with another nurse. Seek research about the disorder.
Seek research about the disorder.
A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? The client states, "I hope that I am able to attend my daughter's wedding." The client states, "I am sure the doctors have misdiagnosed me." The client makes funeral plans. The client asks about hospice services.
The client states, "I am sure the doctors have misdiagnosed me."
The nurse is getting ready to change the client's wound dressing. Which step best supports infection control? sterile gauze sterile gloves handwashing clean environment
handwashing
The nurse is providing teaching to an older adult with arthritis and an implanted catheter. What living arrangement does the nurse anticipate in the discharge plan of care? long-term care facility admission assisted living arrangement home nursing visits continued inpatient admission
home nursing visits
During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: inform the client of the maintenance of confidentiality. review literature pertinent to the client's attributes. implement supportive nursing interventions. assess personal feelings regarding similar clinical situations.
inform the client of the maintenance of confidentiality.
The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? "I will mix insulin glargine with insulin lispro at bedtime." "I will test my glucose level before meals and use sliding scale insulin." "I will take insulin until my blood sugar levels are normal." "I will take my medications between meals for maximum effect."
"I will test my glucose level before meals and use sliding scale insulin."
The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? "You should not have left your child alone while you showered." "Is your child breathing at this time?" "Induce vomiting and call 911 right away." "Did you leave the household chemical in reach of your child?"
"Is your child breathing at this time?"
A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk." "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary." "Make sure that you have smoke detectors in your house and that they're in working order." "If your clothes should catch on fire, go to an open area as quickly as possible."
"Make sure that you have smoke detectors in your house and that they're in working order."
What is the most appropriate nursing response when a client with a BMI of 29 expresses concerns of developing hypertension? "Since weight is one factor that can increase the risk of developing hypertension we will refer you to a nutritionist for weight management." "Weight would be a concern if you have additional signs of developing hypertension such as headaches, vision problems, and chest pain." "Clients who have a higher risk for developing hypertension have a BMI of 30 or higher so we will provide you with dietary information and monitor your weight." "Risk factors for hypertension vary among individuals and weight alone is not a cause for alarm."
"Since weight is one factor that can increase the risk of developing hypertension we will refer you to a nutritionist for weight management."
A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? Any partially uncovered sterile package need not be considered contaminated. When a sterile item touches something that is not sterile, it may not be contaminated. A commercially packaged surgical item is not considered sterile if past expiration date. Sterility may not be preserved even when one sterile item touches another sterile item.
A commercially packaged surgical item is not considered sterile if past expiration date.
What nursing care behavior by the nurse engenders a client's trust in the nurse? A nurse tells the client, "Do not worry about the test, I have never cared for anyone that had problems with it." A nurse tells the client, "My shift will be over in 45 minutes, I will let the oncoming nurse know you have questions about tomorrow's test." A nurse answers the client's questions about an upcoming test while completing documentation in the EHR. A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client.
A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client.
In which situation would the SBAR technique of communication be most appropriate? A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke. A nurse is facilitating a family meeting to coordinate a client's discharge planning. A nurse is calling a health care provider to report a client's new onset of chest pain. A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure.
A nurse is calling a health care provider to report a client's new onset of chest pain.
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? An order set An algorithm A standardized care plan Guidelines
A standardized care plan
A nurse is reading a research article from a nursing journal. The nurse is aware that the opening paragraph summarizing the article and the research findings is a good place to start. What part of the article is the nurse reading? Abstract Results Conclusions Review of the literature
Abstract
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? Auscultate the lung sounds and count respirations. Administer oxygen. Perform a pain assessment. Notify the health care provider.
Auscultate the lung sounds and count respirations.
A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing Inadequate Hygiene related to homelessness as evidenced by client's stink Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing
Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor
An oral medication has been ordered for a client who has a nasogastric tube in place. Which nursing activity would increase the safety of medication administration? Bring the liquids to room temperature before administration. Have the client swallow the pills around the tube. Flush the tube with 30 to 40 mL saline before medication administration. Check the tube placement before administration.
Check the tube placement before administration.
A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? Client reports no headache. Client is normotensive. Client is drowsy after lunch. Client lipids are within range.
Client is normotensive.
The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? Client stands at bedside, becomes pale, diaphoretic. Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomatic. Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic After 3 minutes of sitting, BP 100/50; HR 90
Client stands at bedside, becomes pale, diaphoretic.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? Client will have formed stools within 24 hours. Client will eat small meals of bland foods for 3 days. Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days.
Client will have formed stools within 24 hours.
While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?
Collect client subjective and objective data.
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Request a sedative from health care provider Ask visiting family member to stay Assure bed alarms are activated Conceal IV tubing with gauze wrap
Conceal IV tubing with gauze wrap
Which example of client care is not the responsibility of the nurse? Promoting safety and preventing harm; detecting and controlling risks Monitoring for changes in health status Tailoring treatment and medication regimens for each individual Confirming a medical diagnosis
Confirming a medical diagnosis
While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate? Document on the client's chart that the assessment data may be biased. Inform the client of these potential biases and obtain the client's opinion. Verify the information with one or two family members without informing the client. Consult with another nurse for that colleague's description of the assessment or observations.
Consult with another nurse for that colleague's description of the assessment or observations.
Which are benefits of using the nursing intervention classification (NIC) system for the development of interventions? Select all that apply. Creation of a standardized language Justification of the productivity of the nursing staff Determination of which nursing actions the nurse may delegate Assistance in determining the cost of services that nurses provide Demonstration of the impact of nurses
Creation of a standardized language Assistance in determining the cost of services that nurses provide Demonstration of the impact of nurses
A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome? Beginning the plan without family to help Choosing actions that do not solve the problem Developing the plan without client input Failing to update the written plan of care
Developing the plan without client input
While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse? Slow the rate of infusion until client reports relief. Monitor the site closely for any signs of complications. Apply a cool, moist compress for 20 minutes. Discontinue the IV site and restart IV in a new location.
Discontinue the IV site and restart IV in a new location.
A nurse is administering an intradermal injection to a client for a skin allergy test. When the nurse is finished, there is no sign of a wheal or blister at the site of injection. What is the nurse's best action in this situation? Prepare another syringe and administer it to the client at the same site. Document the administration and inform the primary care provider. Document the administration as correctly administered. Choose another site and reinject the medication.
Document the administration and inform the primary care provider.
What is the best nursing intervention to promote health in a client at risk for heart disease? Taking the client's pulse rate daily Informing the client that the client must lose weight Emphasizing a client's strengths to encourage weight loss Instructing the client to adhere to a high-sodium diet
Emphasizing a client's strengths to encourage weight loss
Which activity best helps the nurse apply theory to practice? Client-focused care Theory development Case management Evidence-based research
Evidence-based research
Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death? Fifth Tenth First Eighth
Fifth
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? Hand hygiene is needed after contact with objects near the client. Hand lotions should not be used after hand hygiene. The use of gloves eliminates the need for hand hygiene. The use of hand hygiene eliminates the need for gloves.
Hand hygiene is needed after contact with objects near the client.
A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process? In-service education Continuing education Graduate education Undergraduate studies
In-service education
A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? Individualize the plan to the client. Identify the appropriate nursing diagnoses. Expect to modify the plan significantly. Include the rationale for the interventions.
Individualize the plan to the client.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Request that the UAP place the steps of the task in the framework of the nursing process. Inform the UAP of the importance of following each step listed in the procedure manual. Ask another UAP to observe and assist the UAP in performing the task.
Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.
A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Limit the resident's fluid intake in order to reduce his or her urge to void. Increase the resident's physical activity to reduce evening restlessness. Investigate the possibility of discontinuing his or her catheter. Collaborate with the resident's health care provider to have his or her diuretics discontinued.
Investigate the possibility of discontinuing his or her catheter.
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?
Notify the health care provider for additional orders
What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered? Nurses now spend time looking up the best way to give nursing care. Nursing care now uses EBP as a means of ensuring quality care. Nursing care now incorporates research studies into client care. Nurses now have to take part in research.
Nursing care now uses EBP as a means of ensuring quality care.
A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case? Nursing standards Nursing orders Nursing process Nurse practice acts
Nursing process
Nurses in an ICU noticed that their clients required fewer interventions for pain when the ICU was quiet. They then asked a researcher to design a study about the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the ultimate goal of expanding the nursing body of knowledge? Nursing research draws conclusions about the quality of client care. Nursing research helps improve ways to promote and maintain health. Nursing research explains ongoing medical studies to clients, and asks for participation. Nursing research involves clients in their care while hospitalized.
Nursing research helps improve ways to promote and maintain health.
At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented? Covert Objective Subjective Symptomatic
Objective
The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide? Wait inside until emergency personnel arrive. Recommend that carbon monoxide detectors be installed in the home. Open doors and windows. Allow emergency personnel to apply oxygen.
Open doors and windows.
When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship? Working phase Orientation phase Intimate phase Termination phase
Orientation phase
The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? Buy protective sporting equipment. Peer pressure causes children of this age to take risks. Place all household cleaners out of reach. Supervise your child on the changing table.
Peer pressure causes children of this age to take risks.
A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: Peer review Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Quality and Safety Education for Nurses (QSEN) American Association of Critical-Care Nurses (AACN)
Peer review
A group of nurses is planning to investigate the effectiveness of turning immobilized stroke clients more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which element will the "O" in the team's PICO question refer to? Turning clients more frequently Clients who have experienced a stroke Preventing skin breakdown The currently used turning schedule
Preventing skin breakdown
An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls? Provide a bedside commode and ensure adequate lighting. Obtain an order for insertion of an indwelling urinary catheter. Accompany the client to the bathroom every 4 hours around the clock. Limit the client's fluid intake during the evening.
Provide a bedside commode and ensure adequate lighting.
While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action? Obtain the client's blood to be tested for HIV and HBV. Request counseling on the potential for infection. Report the needlestick to the nurse manager. Document the injury.
Report the needlestick to the nurse manager.
The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? Ask the client's learning style, then teach diet information using that style. Answer the client's questions about diet alterations, and then evaluate understanding. Present the client with videos and books about diet changes that reduce inflammation. Start from client's knowledge, teach about diet modifications, and check for learning.
Start from client's knowledge, teach about diet modifications, and check for learning.
A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? Supervisory Psychosocial Coordinating Supportive
Supportive
The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? Supportive Maintenance Surveillance Collaborative
Surveillance
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? Educational Psychomotor Surveillance Maintenance
Surveillance
The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply. Admits to drinking wine through the evening Participates in a walking club Takes furosemide daily Has history of diabetic neuropathy Shares a one floor living space with a spouse
Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy
The nurse asks a client about his spiritual health. Which statement best explains the standard of care utilized by the nurse? The RN collects comprehensive data. The RN prays with clients. The RN collaborates with spiritual healers. The RN provides spiritual counseling.
The RN collects comprehensive data.
The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. The client is an architect. The client denies the need for education. The client is blind. The client is male. The client is married.
The client denies the need for education. The client is blind.
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. The client tells the nurse that the client's spouse will handle the care. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions. The client asks the nurse to repeat the instructions.
The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions.
The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. The IV is not infusing at the correct rate. There is spilled water on the floor. The skin is a bluish-color. The client's television is turned off. The client is wearing the oxygen around the neck.
The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color.
When administering beta blocker medications, the health care provider adds an order to hold medication when the client is bradycardic. Which statement explains this order? The client's pulse rate is below 60 beats per minute. The client's respiratory rate is less than 18 breaths per minute. The client is unable to stay upright when blood pressure is checked. The client's systolic blood pressure is less than 100 mm Hg.
The client's pulse rate is below 60 beats per minute.
The nurse should consider which client aspect as nonverbal communication? The client's tone of voice The client's religious practices The client's accent The client's values and beliefs
The client's tone of voice
Which nurse is using criteria to determine expected standards of performance? The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. The nurse manager provides the staff nurse feedback regarding job performance for the previous year. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education.
The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.
Which of the following best summarizes the evaluation step of the nursing process? The nurse completes a health assessment to establish a database. The nurse and client measure achievement of planned outcomes of care. The nurse and client identify nursing diagnoses and appropriate interventions. The client and family have met health care goals and no longer need care.
The nurse and client measure achievement of planned outcomes of care.
The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up? The nurse explains each procedure twice to prevent client questions from wasting time. The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse encourages the client to participate in all treatment decisions as the center of the health care team.
The nurse encourages the client to participate in all treatment decisions as the center of the health care team.
The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities? The nurse stops the instruction and tells the client that a call will be placed to the health care provider to get an order to have a home health nurse administer the medication. The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe. The nurse continues with the instructions and makes a mental note to repeat the initial instructions at the end of the training. The nurse asks the client if he or she is worried about giving oneself an injection.
The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe.
Which client's blood pressure best describes the condition called hypotension? The systolic reading is below 120 and the diastolic reading is below 80. The systolic reading is above 110 and diastolic reading is above 80. The systolic reading is above 102 and diastolic reading is above 60. The systolic reading is below 100 and diastolic reading is below 60.
The systolic reading is below 100 and diastolic reading is below 60.
The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals? To prevent illness To promote health To facilitate coping To restore health
To restore health
Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? Assisted ambulation Limit fluids to 1,000 ml per day Tracheobronchial suctioning Mechanical ventilation
Tracheobronchial suctioning
A nurse working in a long-established hospital learned a specific approach to administering intravenous injections from the previous generation of nurses at the hospital. This is an example of which type of knowledge? Authoritative knowledge Philosophy knowledge Traditional knowledge Scientific knowledge
Traditional knowledge
A pediatric nurse is discussing injury prevention with a group of new parents. What are the leading causes of mortality and morbidity in children? Select all that apply. Unintentional gunshot wounds Drowning Accidental poisoning Suffocation Complications of medical care
Unintentional gunshot wounds Drowning Accidental poisoning Suffocation
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding confirms the client has developed an infection? The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C). The nurse notes the client's urine is dark yellow with sediment. The client reports nausea and vomiting. Urine culture is positive for vancomycin-resistant enterococci (VRE).
Urine culture is positive for vancomycin-resistant enterococci (VRE).
The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: a physiologic outcome. a cognitive outcome. an affective outcome. a psychomotor outcome.
a cognitive outcome.
A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? administering blood products administering intravenous push medication administering bedside blood glucose testing administering chemotherapy
administering bedside blood glucose testing
The nurse is preparing to administer a bolus of an intravenous medication. How should the medication be administered? in tandem with another medication all at once over 3 hours over the duration of a 12-hour shift
all at once
A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess? productive cough dyspnea clear mucus abnormal breath sounds
clear mucus
Which client does the nurse recognize will require an intramuscular administration of the medication instead of an intravenous administration? client who is beginning treatment with chemotherapy following a diagnosis of ovarian cancer client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination client who is in the emergent phase of a 50% partial-thickness (second-degree) burn and requiring medication for pain client who is diagnosed as having sepsis and is prescribed antibiotic therapy
client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination
The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? reverse isolation airborne droplet contact
contact
The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe? decreased risk for infection less frequent administration of the medication decreased irritation and pain in subcutaneous tissue more rapid administration of the medication
decreased irritation and pain in subcutaneous tissue
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measure will the nursing staff implement to help prevent the spread of MRSA to clients who are currently negative for MRSA? prophylactic antibiotic therapy for higher-risk clients who are negative for MRSA early discharge for clients who are positive for MRSA when medically appropriate consistent use of gloves when on the unit diligent hand hygiene
diligent hand hygiene
The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing: wheezing. dyspnea. stridor. fremitus.
dyspnea.
A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don PPE. Which would be appropriate? Select all that apply. respirator gown gloves mask with face shield
gloves gown mask with face shield
When administering immunizations, the nurse is engaged in: coping facilitation. health restoration. illness prevention. health promotion.
illness prevention.
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? bath blanket indwelling catheter specimen containers face shields
indwelling catheter
A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? signs and symptoms of infection vital sign monitoring hand hygiene measures intravenous antibiotic administration
intravenous antibiotic administration
The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity? placing the secondary infusion higher than the primary solution placing the primary solution higher than the secondary solution stopping the primary solution until the secondary infusion is completed placing the secondary and primary infusion at equal height
placing the secondary infusion higher than the primary solution
Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? clears a path from bed to bathroom places bed at lowest setting has client sit in bed for a few moments before standing provides slippers for ambulation
provides slippers for ambulation
A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature? axilla mouth rectum ear
rectum
A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which sign(s) and symptom(s) will the nurse assess related to this condition? Select all that apply. temperature of 100.4°F report of feeling dizzy when sitting up from a supine position report of feeling lightheaded when sitting up report of feeling palpitations when rising from a supine to a standing position erythema on the bilateral lower extremities syncope
report of feeling dizzy when sitting up from a supine position report of feeling lightheaded when sitting up report of feeling palpitations when rising from a supine to a standing position syncope
The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: outcome. subjective. process. structure. goal.
structure
The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply. weight temperature blood pressure allergies pulse respiratory rate
temperature pulse respiratory rate blood pressure
A pulse deficit is the difference between palpated and auscultated blood pressure readings. the systolic and diastolic blood pressure readings. the radial pulse and the ulnar pulse rates. the apical and the radial pulse rates.
the apical and the radial pulse rates.
