NURS 353 - Exam #3 (Engage Fundamentals Quizzes)

A nurse is admitting a cllent for surgery. Which of the following questions should the nurse ask to determine the client's health literacy level and learning needs?A. "Who will be your support person while you are in the hospital?"

"How comfortable are you with out medical forms by yourself?"

A nurse is interviewing a client who is in distress and tells the nurse, "My ex-partner is suing for full custody of my children. I am so worried and don't know what to do." Which of the following questions should the nurse ask to evaluate the client's coping skills?

"What strategies have you used in the past to deal with stress?"

A nurse is caring for a client for who recently lost their job. Which of the following actions should the nurse take during the assessment step of the nursing process?

-Identify whether the client is experiencing feelings of grief. -Check the client for physical manifestations of grief. -Ask the client about their support system.

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include?

-Inspect the feet every day -Wear closed-toe shoes -Manage glucose levels

A nurse is assessing a client who was sexually assaulted 6 months ago and has been diagnosed with post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

-Intrusive memories of the event -Flashbacks of the event -Exaggerated startle response when reminded of the event

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the clients ability to make a healthy behavior changes. which of the following statements by the nurse is an example of the use of affirmations?

"I'm glad you decided to continue your fitness routine."

An employee health nurse is providing teaching about sleep promotion to a group of newly licensed nurses. Which of the following statements should the nurse include?

"If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music."

A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make?

"It is a test that determines if there is nerve damage affecting a muscle."

A nurse is caring for a college student admitted for acute alcohol intoxication. The client reports feeling overwhelmed and expresses an inability to cope with stressors at school. Which of the following statements should the nurse make?

"Let's talk about the coping methods that have worked for you in the past."

A nurse is evaluating a client after measures to promote comfort have been implemented. Which of the following statements by the client indicates that the client has been comforted?

"My health care team has helped me to feel safe during my stay."

A nurse is discussing the nurse's role in client education with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of a nurse's role?

"Nurses make up the greatest percentage of members on a health care team"

A nurse is assisting with teaching a newly licensed nurse about preoperative teaching. Which of the following statements should the nurse include?

"Preoperative teaching can reduce the length of the client's hospital stay."

A nurse is reinforcing teaching about the concept of comfort with a newly hired assistive personnel (AP). Which of the following statements by the AP indicates an understanding of comfort?

"Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy."

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?

"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."

A nurse is assisting a charge nurse with providing an in-service for a group of staff nurses about the physiological functions of sleep. Which of the following statements by one of the staff nurses indicates an understanding of the teaching?

"The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake."

A charge nurse is discussing Worden's Four Tasks of Mourning with a newly licensed nurse. Which of the following statements should the charge nurse include?

"The pain of grief is experienced during the second task."

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

Alzheimer's disease

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and reports discomfort and nausea. The nurse notes minimal bowel sounds on auscultation. The nurse should anticipate that the client may have which of the following conditions?

An ileus

A nurse is caring for a client who was recently diagnosed with chronic kidney disease. The client asks the nurse, "Why me? This is not fair." The nurse should identify the client's statement as an expression of which of the following stages of grief?

Anger

A nurse is discussing types of grief with a group of clients who have a serious illness. Which of the following information should the nurse include?

Anticipatory grief occurs prior to the actual loss of someone or something.

A nurse is preparing to start an iv for a client who has a high risk for bleeding. Which of the following actions should the nurse take?

Apply a blood pressure cuff set to 30 mm Hg.

A hospice nurse is caring for a client who state that they want to have their last rites before they die. the nurse recognizes that which of the following factors is influencing the clients request?

Cultural factor

A nurse is reviewing information about client education with a newly licensed nurse. Which of the following information should the nurse include as the focus of client education?

Empowering clients to be accountable for self care

A nurse is using the NURSE mnemonic while speaking with a client who is experiencing grief. Which of the following responses by the nurse demonstrates the concept represented by the "U" in the NURSE mnemonic?

"There is a lot going on right now, how can I be of help to you?"

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make?

"This test is performed using lenses of various prescription strengths."

A nurse is providing teaching to a client who has a new prescription for eye drops. Which of the following teaching strategies is an example of using the psychomotor domain of learning ?

Ask the client to teach-back about how to use the medication

A nurse calls the unit to tell say that they will be late for their shift. the charge nurse responds, "dont worry, take your time and be safe." after hanging up the phone, the charge nurse then says to staff at the nurses station "im tired of that nurse always being late. i wish someone would do something about their tardiness." which of the following communication styles is the charge nurse demonstrating?

Passive-aggressive

A nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following info should the nurse include?

Perform ROM exercises on the extremity containing the IV site

A nurse is assessing a postoperative client prior to a teaching session. The nurse notes that the client is grimacing and restless. Which of the following barriers to learning is the client exhibiting ?

Physical discomfort

A nurse is conducting an educational session for clients who report experiencing stress-related disorders. A client asks the nurse which part of the body activates the stress response. Which of the following responses should the nurse provide?

Hypothalamus

A nurse is reviewing the ABG values for a client and notes the following results: pH 7.49, PaCo2 39mm Hg, and HCO3 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances?

Metabolic alkalosis

A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority?

Monitor the client's oxygen saturation.

A nurse is collecting data from a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions?

Narcolepsy (NT1)

A nurse is contributing to a presentation about nonpharmacological interventions used to promote sleep. Which of the following information should the nurse recommend including in the presentation?

Nonpharmacological interventions used to help promote sleep include acupuncture and thermotherapy.

A nurse is obtaining a health history from a client who is newly admitted. the nurse notices that the client does not make eye contact and that their arms are folded across their chest. the nurse should recognize that the client is using which of the following forms of communication?

Nonverbal

A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which of the following findings should the nurse identify as a risk factor for obstructive sleep apnea?

Obesity

A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify that which of the following is a characteristic of older adult sleep patterns that might explain the client's frequent awakenings?

Older adults tend to spend more time in stage 2 sleep.

A nurse is reviewing a client's latest ABG report. Which of the following values should the nurse identify as priority to report to the provider?

PaO2 76 mm Hg

A nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk?

Parkinson's disease

A nurse has completed assessing and analyzing data for the client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next?

Planning

A nurse is caring for a client whose partner recently died. In which step of the nursing process should the nurse and client identify the goals for the client's care?

Planning

A nurse is talking about implementing self-care strategies to cope with the stress of caregiving with the partner of a client who has dementia. Which of the following strategies reported by the partner should the nurse identify as an example of effective coping?

Practicing deep breathing while sitting outside

A client is having surgery on their hand and tells the nurse that they understand that anesthesia will be administered so that they will have a temporary loss of feeling in their arm. Which of the following types of anesthesia is the client describing?

Regional

A charge nurse is preparing an in-service for staff members about spiritual influences on grief. Which of the following information should the nurse include?

Religion can provide comfort during the grieving process.

A nurse is assisting in planning postoperative care for a client who is scheduled for surgery. Which of the following interventions should the nurse include in the plan?

Reposition the client every hour.

A nurse is providing teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Request a medical translator to be present

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. which of the following actions should the nurse take?

Request assistance from the facility's interpreter

A nurse is reviewing lab results for a client and notes the following ABG values: pH 7.31, PaCO2 49mm Hq, and HCO3 25mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances?

Respiratory Acidosis

A nurse is caring for a client who has refused to have a biopsy. the client states, "i dont need the biopsy; it wouldnt do anything about it anyways if its cancer." the nurse replied "you dont want to have the biopsy because you would not seek treatment if it was cancer. is that correct?" which of the following therapeutic communications techniques is the nurse using?

Restating

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss.

A nurse manager is planning to introduce a new scheduling policy at the unit staff. which of the following methods of communication should the nurse manager use?

Schedule a face-to-face unit staff meeting

A nurse is providing discharge instructions to a client during a follow-up telephone call. based on the shannon-weaver communication model, which of the following components of the model is the nurse demonstrating?

Sender

A nurse is caring for a client who is scheduled for surgery and is at risk for postoperative venous thromboembolism (VTE). Which of the following prescriptions should the nurse anticipate to reduce the risk of VTE?

Sequential compression devices

A nurse is preparing a low-stimulus environment for an educational session on smoking cessation. Which of the following should the nurse implement?

Set the thermostat to a comfortable temperature.

A nurse is discussing the time-out procedure with a newly licensed nurse. The nurse should include that a time-out is performed at which of the following times?

Several times throughout the procedure

A nurse is assessing a client who is experiencing disenfranchised grief. Which of the following findings should the nurse expect?

Social isolation

A nurse is caring for a client who has dementia. which of the following communication strategies should the nurse implement to communicate with the client?

Speak to the client clearly and at a slow pace

A nurse is discussing the stages of the sleep cycle with a client. The nurse should include that the immune system is strengthened and tissues and bones are repaired during which of the following stages of the sleep cycle?

Stage 3

A nurse is reviewing a client's plan of care. "The client will ambulate 20 feet using a walker" is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify as missing from the outcome?

Timed

A nurse is caring for a client who takes an over-the-counter (OTC) sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effect of OTC sleep aid medications?

Urinary retention

A nurse in the PACU is determining if a client has pain. the client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. which of the following actions should the nurse take?

Use an alternative method for determining the clients pain level

A nurse is preparing for a teaching session with a client who has pernicious anemia. Which of the following should the nurse identify as part of the implementation step of the teaching process?

Use demonstration to teach the client about vitamin B12 injections.

A nurse is caring for a client who has a prescription to receive one unit of packed red blood cells. The clients blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take?

Verify the unit of blood with another nurse.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII?

Whisper something in one ear while occluding the other ear.

A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make?

You can receive a blood donation from donors with type O- and type O+ blood.

Surgical attire for the surgical suite consists of which of the following items?

-Cap -Shoe covers -Gown -Mask -Gloves

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching?

-A walking cane -A walker

A nurse learns that a coworker has died unexpectedly. Which of the following actions should the nurse take?

Recognize their feelings of grief.

A nurse is discussing the Dual Process Model of Grief with a newly licensed nurse. Which of the following statements should the nurse make?

"A client's grief will oscillate between loss-oriented grief and restoration-oriented grief."

A nurse is caring for a client who has delivered a healthy newborn. The client is tense, refuses to hold the baby, and tells the nurse, "I have no idea how to handle having a baby. I wish this pregnancy had never happened." Which of the following statements should the nurse make?

"Becoming a parent is a new experience for you. Let's talk about your concerns."

A nurse is orienting a newly licensed nurse to the unit. Which of the following statements by the newly licensed nurse indicates an understanding of the importance of documentation of client education?

"Client documentation can increase staffing and services."

A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea?

"Common causes of central sleep apnea are opioid overdose and congestive heart failure."

A nurse is providing teaching to a client who has a recent diagnosis of pancreatic cancer. The nurse is using strategies in the affective domain of learning. Which of the following client statements is part of the affective domain?

"I have been crying a lot since I learned about my diagnosis. I'm worries about everything."

A nurse is conducting a preoperative assessment of a client. which of the following statements is an example of the nurse using motivational interviewing?

"You said that you're sad. what is making you feel sad?"

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make?

"You will have a small probe placed in your ear canal during the test."

A nurse is caring for a client who requires a replacement peripheral iv. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheters should the nurse plan to use?

#22-gauge

A nurse is caring for a client who has migraine headaches and reports that they are "getting worse." Which of the following questions should the nurse ask the client to determine if the headaches are a stress-related disorder?

-"What is the intensity of your migraine headaches?" -"How often do the migraine headaches occur?" -"What type of support is available to you when you have a migraine headache?" -"What coping strategies do you use when you experience a migraine headache?"

A nurse educator is planning an in-service for staff nurses about psychomotor client teaching strategies. Which of the following activities requires the use of gross motor skills?

-A client walking with crutches -A client using a manual wheelchair

A palliative care nurse is preparing an in-service for newly hired staff members about common grief reactions. Which of the following information should the nurse include?

-A client who is grieving often experiences a wide range of emotions. -A client may feel a sense of relief if the death of a loved one was expected. -A client may experience difficulty concentrating and hallucinations as a psychological response to loss. -Behavioral responses to grief can include the refusal to eat or participate in social activities.

A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their donation. Which of the following responses should the nurse make?

-A+, -AB- -AB+ -A-

A nurse is collecting data from a client who is preoperative for a surgical procedure. Which of the following information should the nurse document in the client's medical record?

-Allergies -Alcohol use -Spiritual beliefs

A nurse is assessing a client's health literacy prior to providing education. Which of the following actions should the nurse take?

-Ask questions regarding the client's health care needs and concerns -Obtain a health history -Assess the client's education level

A nurse is assisting in developing a plan to manage a client's perioperative pain. Which of the following interventions should the nurse include in the plan

-Ask the client what interventions they prefer. -Determine how the client has responded to analgesics in the past. -Include nonpharmacological methods to reduce pain.

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss?

-Asks for questions to be repeated -Withdraws from social activities -Describes sounds as being muffled

A nurse is preparing for a teaching session with a client. Which of the following actions should the nurse take to provide the client with unbiased care?

-Avoid assumptions about the client. -Control personal thoughts about the client -Collaborate with another nurse to develop teaching strategies .

A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective?

-Client states their muscle spasms are absent -Client denies being confused

A charge nurse is reviewing Kübler-Ross's five stages of grief with a newly licensed nurse. Which of the following statements should the nurse make?

-Clients might not go through all five stages of grief. -Clients can return to a stage of grief after moving into one of the other stages. -Client who are grieving might attempt to bargain with a higher power.

A nurse is caring for a client whose spouse recently died. The client is from a different culture than the nurse. Which of the following information should the nurse consider when caring for the client?

-Cultural-based rituals can assist clients in handling the death of a loved one. -Culture may determine how a client expresses their grief. -Rituals regarding death direct what procedures are performed on the body after death.

A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients?

-Decreased kidney function -Decreased thirst response -Decreased total body fluid

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect?

-Difficulty maintaining attention -Agitation -Hallucinations -Rambling speech

A nurse is reviewing ABG values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect?

-HCO3 19 mEq/L -pH 7.29 -PaCO2 35 mmHg

A nurse is caring for a client whose partner was recently hospitalized with COVID-19. The client is experiencing manifestations related to the alarm stage of general adaptation syndrome (GAS). For which of the following manifestations should the nurse monitor?

-Hypertension -Dilated pupils -Increased state of arousal

A nurse is reviewing the goals of client education with a newly licensed nurse. Which of the following information should the nurse include?

-Improvement of health -Provide knowledge about an illness or injury -Health promotion

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic?

-Loop diuretics -NSAIDS -Aminoglycoside antibiotics

A nurse is assessing a client who came to the ED reporting chest pain. the client tells the nurse that they have hearing loss and forgot to bring their hearing aid with them. which of the following actions should the nurse take to improve communication with the client?

-Move the client to a quiet area or private room -Speak at a slower pace -Avoid using medical terminology

A nurse is providing discharge teaching about health promotion to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following instructions should the nurse include?

-Practice mindful breathing. -Start each day with a to-do list. -Develop habits to mitigate stress.

A nurse is caring for a client who has a new prescription for dialysis three times a week. the client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. the client also states, "i dont know how i am going to have time for dialysis." which of the following factors are influencing the clients communication?

-Psychosocial factors -Situational factors

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. which of the following statements should the nurse include?

-Respect the client during conversation -Allow time for reflection during the conversation with the client -Show empathy during conversation with the client

A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines?

-Sensory overload -Sleep deprivation

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age?

-Sour -Bitter -Salty

A nurse is collecting data on the surgical wound of a postoperative client. Which of the following information should the nurse include in the documentation of the wound?

-The client states the wound is painful -The edges of the wound are red -The client has a fever

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss?

-Trauma to the outer ear -Inflammation -Cerumen buildup -Otitis media

A nurse is reviewing the medical record of a postoperative client. Which of the following findings in the client's history are risk factors for poor wound healing?

-Type 2 diabetes mellitus -Current smoker -Corticosteroid -68 years old

A nurse is planning to teach a new assistive personnel (AP) how to use a bedside glucose monitor to check a clients blood glucose level. the nurse will include a 30 min face-to-face lecture and a written copy of the step-by-step procedure. which of the following modes of communication is the nurse using in the teaching plan?

-Verbal -Written -Nonverbal

A nurse is reinforcing teaching with a newly licensed nurse about informed consent. The nurse should include that which of the following is the nurse's responsibility when obtaining informed consent from a client?

-Verify the client has signed the consent. -Check that the client is of legal age to provide consent. -Confirm the client is competent.

A nurse is caring for a client who is 4 days postoperative following a below-the-knee amputation related to a work injury. The nurse should identify that which of the following are components of the client's self-concept that this injury can impact?

-body image -role performance -identity -self-esteem

A nurse is reviewing the plan of care for a client who was recently divorced. Which of the following interventions should the nurse include to promote the client's positive self-concept?

-encourage the client to identify past and current accomplishments -encourage the client to verbalize perceptions that indicate a healthy self-esteem -assist the client to identify healthy coping strategies and support systems -collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care

A nurse is meeting with a client at a community health center to assess their self-concept. Which of the following factors should the nurse consider during the assessment?

-life experiences -societal and cultural attitudes -health status -academic achievement

A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate.

0.9% sodium chloride solution

What is the stages of the nursing process (in order)?

1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation

A nurse is planning a teaching session for a client. Place the steps of the teaching process in the correct order.

1.Assessment 2.Analysis 3.Planning 4.Implementation 5.Evaluation

A nurse is reviewing Kübler-Ross's five stages of grief. The nurse should identify that Kübler-Ross placed the stages in which original order?

1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance

A nurse is preparing a client for surgery and needs to scrub the surgical site. Identify the sequence the nurse should follow.

1.Scrub the surgical site in a circular fashion with an antiseptic is the first step. 2.Start at the center and move to the area away from the site is the second step. 3.Scrub the outer edge and discard the sponge is the third step. 4.Repeat with a new sponge is the fourth step. 5.Drape the client is the fifth step.

A nurse is calculating a client's intake and output for the last 4hr. The client consumed 480ml of water and 240ml of coffee. The client also received IV fluids for 4 hr infusing at 100ml/hr. Which of the following represents client's intake over the last 4 hr?

1120ml

A nurse is reviewing a client's lab results. Which of the following results should the nurse report to the provider?

Magnesium 3 mEq/L

A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan to infuse the blood over which of the following length's of time?

4 hr

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

A nurse is caring for a client who is postoperative following a femur fracture repair. The client suddenly reports chest pain and is experiencing shortness of breath. Which of the following conditions should the nurse suspect?

A pulmonary embolism

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse is caring for a client who has the following ABG values: pH 7.44, PaCO2 37 mm Hg, and HCO3 24 mEq/L. The nurse should identify that these values are an indication of which of the following?

Acid-base balance

A nurse in a community clinic is interviewing a client who is distressed and reports being unable to sleep following a neighborhood fire several days ago. The client has hypertension, tachycardia, and is diaphoretic. The nurse should identify that the client is experiencing which of the following types of stress?

Acute stress

A nurse is interviewing a client who recently experienced an act of workplace violence when an armed person held the workers at gunpoint before police intervened. The client now reports being anxious and fears the gunman might return. The nurse should identify that the client is experiencing which of the following types of crisis?

Adventitious

A nurse in a health clinic is interviewing a client who is upset and reports that their stress "is too much to handle." The client is unemployed, a single guardian to young children, and has periodic asthma attacks. Which of the following stress-related conditions is the client experiencing?

Allostatic load

A nurse is providing teaching about performing blood glucose checks to a client who has a new diagnosis of diabetes mellitus. Which of the following actions indicates the nurse is using the affective domain of learning?

Ask the client how they feel about checking their blood glucose levels

A nurse is reinforcing teaching provided to a client about postoperative complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia?

Aspiration

A nurse is assisting a postsurgical client who has had previous trouble swallowing prepare for a meal. Which of the following actions should the nurse take?

Assist the client to sit upright to eat.

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?

Availability of aids to enhance vision

A nurse is caring for a client who is in crisis following the breakup of a long-term relationship. The client tells the nurse, "I might as well just die. My life is over." Which of the following actions should the nurse take first?

Conduct a suicidal risk evaluation.

A nurse is caring for a client who has impaired cognition and has begun taking a new medication. Which of the following actions should the nurse take during client education ?

Direct the education to the caregivers as well as the client.

A nurse is caring for a client who is preoperative and reports a history of regular tobacco use. The nurse should identify that the client is at the greatest risk for which of the following postoperative complications?

Blood clots

A nurse is collecting data on a client who is postoperative following a hip arthroplasty. Which of the following findings is a possible manifestation of bleeding?

Blood pressure 88/60 mm Hg

A nurse is reviewing the latest ABG values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process?

Evaluation

Which of the following members of the surgical team is responsible for ensuring that the necessary tools are sterile and ready to use?

Certified surgical technologist

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?

Check the client's visual acuity using a Snellen chart.

A nurse is assessing a client who has been receiving IV therapy for several days and notes that the clients daily weight has increased. The Nurse should identify that the client is at increased risk for developing which of the following IV-related complications?

Circulatory overload

A nurse is teaching a group of newly licensed nurses about client education. Which of the following information should the nurse include in the teaching?

Client education can improve self -care at home

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia?

Client who has vomited 4x the last 8 hr

A nurse is participating in a question-and-answer session with a client. Which of the following domains of learning uses this type client education?

Cognitive Domain

A nurse is instructing a client regarding heart-healthy activities. this action represents which of the following phases of the nurse-client relationship?

Exploitation

A nurse is caring for an older adult client who is having difficulty sleeping and has a new prescription for a medication to help them sleep. Which of the following medications should the nurse identify as a first-line sleep aid for older adults?

Controlled-release melatonin

A nurse is teaching a client who is newly diagnosed with diabetes mellitus. the client tells the nurse, "thank you. i never really knew what caused diabetes." using the Schramm model of communication, the nurse should recognize the clients statement as an example of which of the following components of the model?

Feedback

A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider?

Decrease in level of consciousness

A nurse is caring for a client who has pancreatic cancer that is unresponsive to treatment. The client is experiencing significant weight loss and fatigue, but when the nurse asks how they are feeling, they respond with, "Great! I'm going to beat this cancer." Which of the following defense mechanisms is the client using?

Denial

A nurse is caring for a client who reports that they use their smartphone at night while they are in bed. The nurse should identify that excessive smartphone use can increase the client's risk for which of the following?

Depression

A nurse is evaluating a client's plan of care. The desired outcome of having the client sit on the side of the bed by the end of shift was not met Which of the following actions should the nurse take?

Determine if different nursing interventions are required

A nurse is preparing for an initial visit with a client who is experiencing grief. Which of the following tasks should the nurse plan to complete first?

Develop a relationship with the client.

A nurse is caring for an older adult client who reports being stressed about their health status due to problems with short-term memory, slower reaction times when driving, and urinary frequency. The nurse should recognize that the client is experiencing which of the following types of stressors?

Developmental stressors

A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions?

Diabetes mellitus

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia?

Difficulty problem-solving

A nurse is caring for a client who is having difficulty falling asleep. Which of the following interventions should the nurse implement to promote sleep for the client?

Dim the lights in the client's room at bedtime.

A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first?

Elevate head of client's bed

A nurse is contributing to the plan of care for a client who is postoperative. Which of the following interventions should the nurse recommend including to promote emotional comfort for the client?

Encourage the client to verbalize their needs and concerns.

A nurse is planning teaching for a client about wound care. which of the following actions should the nurse take?

Ensure the client is wearing their glasses during teaching

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client?

Ensure the client wears their hearing aids.Use a sign language interpreter.Communicate using paper and pen.Face the client when speaking.

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. which of the following actions should the nurse take to enhance client learning?

Ensure the room is well lit

A nurse is caring for a client who has delivered a healthy newborn. The client tells the nurse that while they are somewhat stressed about being a new parent, they are thrilled by the birth of their child. The nurse should identify that the client is experiencing which of the following types of stress?

Eustress

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?

Glaucoma

A nurse is caring for an adult client who is mourning the death of a sibling. Which of the following information should the nurse consider when caring for the client?

Grief differs for adults due to their full understanding of death and memories of the deceased.

A nurse is caring for a client who has a new prescription for a nonbenzodiazepine hypnotic to promote sleep. For which of the following adverse effects should the nurse monitor the client?

Hallucinations

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?

Hearing loss

A nurse is contributing to a presentation about hypersomnia. Which of the following information should the nurse recommend including in the presentation?

Hypersomnia does not improve with increased sleep.

A nurse is caring for a client who has narcolepsy (NT1) with cataplexy. The nurse should identify that this condition is caused by a lack of which of the following hormones?

Hypocretin

A nurse receives a phone call from a client who was discharged yesterday. the client asks the nurse to email them a copy of their discharge instructions. which of the following responses should the nurse make?

I am unable to send your discharge instructions via email due to HIPAA privacy act

A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further weight gain for the client?

Increased leptin production

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor?

Infection at the access site

A nurse is planning care for a client who has a distended bladder and has not voided 8 hr after surgery. Which of the following interventions should the nurse plan to take?

Insert a straight urinary catheter into the client.

A nurse is assessing a client who is working at home due to COVID-19 restrictions. The client reports abdominal cramping and bloating with diarrhea and states, "I am completely stressed out from working at home." The nurse should identify that the client is experiencing manifestations of which of the following stress-related conditions?

Irritable bowel syndrome

A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?

Keep the client's environment free from clutter.

A nurse is teaching a client about how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach back method of learning ?

Let me show you how I will take my blood pressure at home each day.

A nurse is assessing a client who is getting divorced and reports feelings of loss associated with no longer being in the role of a spouse. The nurse should identify that the loss of a previously held role is which of the following types of losses?

Loss of identity

A nurse enters a client's room and stands near the client to ask them if they need anything. the client continues to watch the television, which is at a loud volume. which of the following actions should the nurse take?

Lower the volume on the television

A nurse is caring for a client who has dementia and is scheduled for surgery. Which of the following creates a risk for the client to develop a postoperative complication?

Prescribed anticholinergics

A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain medications, which of the following interventions should the nurse implement to promote comfort?

Present information honestly.

A nurse is caring for a client who has been charged with partner violence against their spouse. The client is angry, pacing, and yells out, "I wouldn't lose my temper if my spouse would just leave me alone. It's their fault." The nurse should identify the client is displaying which of the following defense mechanisms?

Projection

A nurse is planning a 30-min group education class. Which of the following actions should the nurse plan to take to address various learning styles related to the domains of learning ?

Provide games, discussion, and question-and-answer.

A nurse is planning a smoking cessation program for a client. Which of the following actions is a component of SMART outcome goals ?

Providing a time frame to accomplish the outcome

A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following findings is a manifestation of an infection?

Redness around the incision site

A nurse is caring for a client who reports experiencing stress over an upcoming surgical procedure. Which of the following statements describes the characteristics of stress?

Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one's state of equilibrium.

A nurse is planning care for a client who is recently divorced with two young children. The client reports difficulty sleeping, feeling hopeless, and being estranged from family. The nurse should plan to monitor the client for which of the following potential manifestations of chronic stress?

Suicide

A nurse is reinforcing teaching with a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the brain transmits the sensory data that is used to develop dreams?

Thalamus

A nurse is assessing a school-age child whose friend recently died. Which of the following findings should the nurse expect?

The child holds back their feelings.

A nurse is assessing a 16-year-old client whose parent recently died. Which of the following findings should the nurse expect?

The client displays high-risk behaviors.

A nurse is caring for a client who needs to be awakened for the administration of an oral medication. Which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened?

The client experiences mental cloudiness for 30 to 60 min.

A nurse is preparing to educate a client about the proper procedure for a dressing change. Which of the following indicates an understanyling of Knowles's fundamental principles of client readiness?

The client is engaged and alert

A nurse is assessing a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for the client's fluid and electrolyte imbalance?

The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day.

A nurse is collecting data on a client who is preparing for discharge following surgery. Which of the following findings should be the nurse's priority concern?

The client takes medications that cause dizziness.

A nurse is using a question -and-answer session to teach a client about a diabetic diet . Which of the following outcomes is an example of cognitive learning ?

The client understands a diabetic meal plan

A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

The nurse selects 0.45% sodium chloride to use to prime the tubing.

A nurse is reviewing factors that can affect a client's self-concept. The nurse should identify that empathy, motivation, and self-awareness are domains of which of the following factors?

emotional intelligence

A nurse is caring for an adolescent client who plans to attend the same law school their parent attended and work at their parent's law firm upon graduation. The client has never questioned their academic and career pathway and states, "If it's good enough for my parent, it's good enough for me." The nurse should identify that which of the following identity statuses describes the client's position?

foreclosure

A nurse is meeting with a client who was recently diagnosed with rheumatoid arthritis. The client tells the nurse, "I'm never going to be able to do anything fun." Which of the following questions should the nurse ask to assess the client's identity?

how do others' opinions impact the way you see yourself

A nurse is assessing the self-concept of a client who recently lost their job and, as a result, might lose their home to foreclosure. Which of the following questions should the nurse ask the client when gathering information regarding self-concept?

how would you describe yourself and your situation

A nurse is caring for a client who reports enjoying retirement because they are reading more, visiting with children and grandchildren, and playing bridge with their friends. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development?

integrity vs. despair

A nurse is meeting with a client who is recovering from a bilateral mastectomy. Since being discharged, the client has changed dressings as prescribed and completed arm exercises. The client tells the nurse, "I'm pleased with my postoperative progress." The nurse should identify that the client is displaying which of the following self-concept characteristics?

self-efficacy

A nurse is collecting data from a client regarding their self-concept and asks, "What are some of the accomplishments that make you feel good about yourself?" The nurse is collecting data about which of the following components of self-concept?

self-esteem