Nursing Concepts Practice Final Exam

A young woman has been in an automobile crash that resulted in an amputation of her left lower leg. She verbalizes grief and loss. What knowledge by the nurse is used to provide interventions to help the client cope? a. This is a normal, appropriate response b. Tissue healing will help with client adapt c. This is an abnormal, inappropriate response d. The client should be grateful to be alive

A

An unconscious client is brought to the emergency department. Which assessment should be implemented first? a. the client's airway should be assessed b. the nurse should determine the reason for admission c. the nurse should review the client's medication d. the client's past medical history should be assessed

A

During a class for 5th-6th grade girst about menstruation, one student comments that she has heard that girls "smell bad" during their menses. Other students chime in saying they have heard the same thing and ask how to prevent odors. The nurse correctly answers with which of the following solutions? a. Utilize good hygiene and regular bathing b. Use deodorizing pads and tampons c. Change pads or tampons at least daily d. Stay at home during heaviest flow

A

During a visit to a pediatrician's office, a parent inquires about toilet training her 2 year old daughter. The nurse informs the mother that one factor in determining toilet training readiness is when: a. The child can recognize bladder fullness b. The child can hold urine for 4-5 hours c. The child cannot control urination until seated on the toilet d. The child ignores the desire to void

A

The client suffered a myocardial infarction (MI) and has shared with the nurse that he is reluctant to resume sexual activity. He is worried about having another MI. The nurse discusses various methods of sexual expression. The nurse also includes in the instruction there is a body area that is most important for sexual arousal and stimulation. What body area does the nurse indicate is most important for sexual arousal and stimulation? a. Brain b. Genitalia c. Breasts d. Skin

A

The client was told of a terminal illness and has been questioning his fath. A spiritual counselor will be visiting the client following a referral. What interventions would the nurse NOT perform to provide an environment that is conducive for both the client and the spiritual counselor? a. Stay in the room with the spiritual counselor for assistance if needed b. Place a chair facing the client next to the bed c. Provide privacy for the client from visitors during the visit from the spiritual counselor d. Clean clutter and unnecessary items from the bedside table

A

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times daily. Which action will be most effective to transfer the client safely? a. Have the client sit on the side of the bed for several minutes before moving to the chair b. Position a friction-reducing sheet under the client c. Infuse an intravenous bolus 15 minutes before transferring the client to the chair d. Obtain a quad cane for the client to use as a transfer aid

A

The nurse is performing an admission assessment on a client who was just transferred from the emergency department. The client has an elevated temperature and a wound infection. The client's sensorium is decreased, but the client is responsive. When should the nurse initiate teaching for this client? a. During the Admission assessment b. When family is not present c. When the client's infection is improving d. At the time of discharge

A

The nurse is planning the discharge of a client who had surgery for a left hip replacement. The client is bring discharged from the hospital to the home and requires a walker and high-rise toilet seat. Which type of home health care service does the client require. a.Home medical services b. High-technology pharmacology services c. Custodial services d. Hospice services

A

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? a. Proliferation phase b. Hemostasis c. Inflammatory phase d. Maturation

A

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the client is exhibiting signs of: a. A dysrhythmia b. Hypertension c. Bradycardia d. Tachycardia

A

What is the primary purpose of the outcome identification and planning step of the nursing process? a. To design a plan of care for and with the client b. To collect and analyze data to establish a database c. To write appropriate client-centered nursing diagnosis d. To interpret and analyze data so as to identify health problems

A

What might a nurse ask during a health history to assess personal identity? a. "How would you describe yourself to others?" b. "Tell me what you do for fun and what you do for work." c. "Tell me how your illness has affected you in your job" d. "How do you believe others see you? Why do you believe that?"

A

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? a. Perform hand hygiene b. Insert a swab into the wound at 90 degrees c. Assess the condition of the visible wound bed d. Measure the width of the wound with a disposable ruler

A

Which client likely faces a risk for the nursing diagnosis of disturbed Sleep Pattern Difficulty Remaining Asleep? a. A client whose opioid analgesic results in central nervous system depression b. A client who receives IV antibiotics every 3 hours c. A client who receives blood glucose checks four times daily d. A client whose physical therapy has been scheduled for 4:30 pm

A

Which guidelines is a correct one to follow when composing a nursing diagnosis statement? a. Place defining characteristics after the etiology and link them by the phrase "as evidenced by" b. Place the etiology prior to the client problem and linked by the phrase "related to" c. Phrase the nursing diagnosis as a client need d. Incorporate subjective and judgmental terminology

A

Which intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU? a. Use limited light b. Play loud music c. Avoid touch d. Use bright lights

A

Which of the following nurses is most likely to care for clients who are trying to resolve identify versus role confusion? a. A nurse who provides care in a large junior high school b. An occupation health nurse based at a lumber mill c. A pediatric nurse d. A nurse who works in a long-term care facility

A

Which statements accurately describes a recommended guideline for implementation? a. Before implementing any nursing action, reassess the client to determine whether the action is still needed b. Assume that the nursing intervention selected is the best of all possible alternatives c. Reduce repertoire of skilled nursing interventions to ensure a greater likelihood of success d. When implementing nursing care, remember to act independently, regardless of the wishes of the client family

A

Which term best describes an individual's self-concept? a. Self-image b. Self-realization c. Self-esteem d. Self-actualization

A

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and yellow exudate can be expressed when the gums are palpated. What condition do these symptoms indicate? a. Periodontitis b. Plaque c. Halitosis d. Caries

A

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? a. As-needed care b. Partial care c. Complete care d. Self-care

B

The nurse formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made? a. The nurse wrote vague outcomes that will confuse other nurses b. The nurse included more than one client behavior in the outcome c. The nurse expressed the client outcomes as a nursing intervention d. The nurse used verbs that are not observable and measurable

B

The nurse is caring for a client with acute back pain. When should the nurse assess the client's pain? a. Once per day when pain is a potential problem b. When the vital signs are measured and documented c. After the client is discharged from the health care facility d. Six hours after administering a prescribed analgesic

B

The nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action should the nurse perform before revising a plan of care? a. Select appropriate nursing interventions b. Discuss any lack of progress with the client c. Collect information on abnormal functions d. Identify the client's health-related problems

B

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which of the following actions is correct? a. Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings b. Remove the antiembolism stockings during the bath c. Fold the antiembolism stockings half-way down to allow assessment of the popliteal pulse d. Leave the antiembolism stockings in place, but be sure to remove all wrinkles

B

The nurse organizes client data using the SOAP format. Which information would be recorded under the "S" of this acronym? a. Client interventions b. Client reports of pain c. Client's chief report d. Client history

B

The nursing instructor informs the student nurse that the client she is caring for has a chronic neurological condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client? a. Diarrhea b. Constipation c. Deficient fluid volume d. Excessive fluid volume

B

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will: a. Continue the plan of care b. Terminate the plan of care c. Modify the plan of care d. Reevaluate the plan of care

B

Using Erikson's theory, which of the following activities would the nurse use to provide a sense of fulfillment and purpose in later adulthood? a. Becoming involved within the community b. Reminiscing about life events c. Trying on new and different roles d. Making a commitment to others

B

What common problem is related to outcome identification and planning? a. Writing nursing orders that are clear and resolve the problem b. Failing to involve the client in the planning process c. Stating specific and measurable outcomes based on nursing diagnosis d. Collecting sufficient data to establish database

B

When documenting subjective data, the nurse should: a. Validate the information with the client's family prior to documentation b. Use the client's own words placed in quotation marks c. Record the information using nonspecific words d. Paraphrase the information stated by the client

B

Which group of terms best describes anxiety? a. Cognitive, known threat, deperssion b. unknown cause, emotional, apprehensive c. Known source, prolonged, solely physical d. Cognitive, visible threat, anger

B

Which illness has been associated with long-term stress? a. Renal disease b. Cardiovascular disease c. Fractures d. Bacterial infections

B

Which of the following tasks could the nurse safely delegate to unlicensed assistive personnel? a. An initial assessment of a client b. Documentation of client's I+O on a flow sheet c. Evaluation of client progress d. Determination of a nursing diagnosis

B

Which outcome is correctly written? a. Abdominal incision will show no signs of infection b. On discharge, client will be able to list five symptoms of infection c. During home care, nurse will not observe symptoms of infection. d. On discharge, client will be free of infection.

B

A child 2 years of age is hospitalized for a surgical procedure. Although previously all fluids were taken from a cup, the toddler wants a bottle to suck on. The nurse recognizes this behavior as what? a. Totally unacceptable b. Abnormal behavior c. Normal regression d. Proof that the child is sick

C

A child learns to feel secure within the bonds of his immediate family by interacting with his caretakers. What is the term for this process? a. Adaptation b. Globalization c. Attachment d. Self-reflection

C

A client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system? a. Blood sugar of 65 mg/dL b. Increased bowel sounds c. Heart rate of 102 beats/min d. Cool, clammy skin

C

A dying client is crying. She states, "Why me, Lord?" and "I can't pray." What would be an appropriate nursing diagnosis based on this data? a. Low self-esteem b. Knowledge deficit related to praying c. Psycho-spiritual distress d. Ineffective coping

C

A male client age 42 years recovering from a MI is having difficulty following the care plan to stop smoking and exercise. What is the nurse's best response to this client? a. Tell him that he will have another MI and it will be his own fault. b. Tell him that his cigarettes will be taken away if he smokes again c. Ignore the behavior and recommend a behavior modification program. d. Tell him that he is not trying hard enough.

C

A middle-aged adult man has just started an exercise program. What would the nurse teach him about exercise and sleep? a. The time of day does not matter, exercise facilitates sleep b. Fatigue from exercise may be a hindrance to sleep c. Exercising within two hours of bedtime can hinder ability to sleep d. Exercising immediately before bedtime can enhance ability to sleep

C

A nurse has developed a plan of care to meet the needs of a client with the nursing diagnosis of Spiritual Distress. What would be an expected outcome? a. Commit to reading passages from the Bible daily b. Share feelings about religion with other health care providers c. Identify factors in life that challenge spiritual beliefs d. Attend church services on a weekly basis

C

A nurse is assessing a client's gustatory function. What approach by the nurse will assist in assessing this sensation? a. "Please read this paragraph to me." b. "Close your eyes and tell me what your smell." c. "Tell me if the taste on your tongue is sweet, sour, bitter, or salty." d. "Repeat the words that I speak softly to you."

C

A nurse is caring for a client who is experiencing fluid volume deficit. Which of the following signs do not correlates with a fluid volume deficit? a. Decreased blood pressure b. Reduced skin turgor c. Increased respiratory rate d. Increased pulse rate

C

A nurse is feeding a client. Which statement would help the client maintain dignity while being fed? a. "I am going to feed you your cereal first, then your eggs." b. "I wish I had more time so I could feed you all your meal" c. "What part of your dinner would you like to eat first?" d. "I know you don't like me to feed you, but you need to eat"

C

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? a. By carefully handling them with clean hands b. By clean hands wearing clean latex gloves c. With sterile forceps or hands wearing sterile gloves d. With clean forceps that touch only the outermost part of the item

C

A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next? a. Make assessments every 15 minutes for four hours b. Reassure the family that this is a common problem c. Apply a pressure dressing and report findings d. Document the data and apply a new dressing

C

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem? a. "I often have diarrhea after I eat spicy foods" b. "I just feel so bad about myself these days" c. "I get out of breath when I walk a few steps" d. "My skin is so dry I just can't keep from scratching"

C

A staff development nurse is discussing techniques for prevention of back injury with a group of nurses aids. The nurse informs the group that back stress and injury can be prevented by: a. Using the strength of back muscles during strenuous activity b. Holding the object you are lifting/moving away from the body c. Spreading the feet shoulder-width apart to broaden the base of support d. Pulling equipment rather than pushing it when possible

C

An individual wakes up from sound sleep in the middle of the night because of abdominal pain. Why does this happen? a. Messages from baroreceptors to the spinal cord b. Messages from chemo receptors to the brain c. Stimuli from peripheral organs to the RAS d. Stimuli to the wake center in the cerebral cortex

C

An older adult woman in a long-term care facility has fallen and sustained several injuries. Which of these injuries would be the most serious fall-related injury? a. Fractured ulna b. Lacerated lip c. Fractured hip d. Thigh contusion

C

Based on knowledge of total body fluids, a nurse is especially watchful of a fluid volume deficit in an infant. Why would the nurse do this? a. Infants lose more fluid through output than adults b. Infants drink less fluids than adults c. Infants have more total body fluid and ECF than adults d. Infants have less total body fluid and ECF than adults

C

Parents of an infant express concern because the infant is touching his genitals. What should the nurse teach the parents? a. Have the child wear clothes that prohibit touching b. If this bad behavior continues, seek counseling c. Self-manipulation of genitals is normal behavior in an infant d. Make him have a "time out" every time it happens

C

The client has lost 2 lb of the 5 lb/month goal. How should the nurse alter the plan of care in response to this new data? a. The nurse should not alter the plan of care b. The nurse should delete the nursing diagnosis c. The nurse should modify the time criteria d. The nurse should change the diet

C

The following foods are 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? a. Decrease high-fiber foods b. Decrease amount of fluids c. Nothing, this is a good diet d. Omit fruits if eating vegetables

C

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? a. Outcome identification b. Assessment c. Evaluation d. Implementation

C

The nurse has been working with a client for several days during the client's recovery from a femoral head fracture. How should a nurse best evaluate whether client education regarding the prevention of falls in the home has been effective? a. "Do you think that the safety measures I taught you are clear and realistic?" b. "In light of what we've talked about, why is it important that you remove the throw rugs in your home?" c. "What changes will you make around your house to reduce the chance of future falls?" d. "Do you have any questions about the fall prevention measures that we've talked about?"

C

The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? a. The diagnosis present significant risks for the development of medical diagnoses b. The diagnosis has yet to be confirmed by another practitioner c. The client is more vulnerable to certain problems than other individuals would be d. The data necessary to make a definitive nursing diagnosis is absent

C

The nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition? a. Orthostatic hypertension b. Ambulatory bredycardia c. Orthostatic hypotension d. Amnbulatory tachycardia

C

The nurse is initiating a 24 hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of a specimen collection? a. Add the first void to the specimen b. Begin the collection at a specific time c. Void and discard the urine. d. Keep the urine warm during collection

C

The nurse makes the following assessment of a hospitalized client. Abdomen is soft. Urinary bladder is nonpalpable. Foley catheter is present. 600 mL of cloudy amber urine is present in urinary collection bag. What information does the nurse chart in the computerized nurses notes? a. Urine is clear. b. Urine output is 600 mL c. Foley catheter is present and urine is amber in color. d. Abdomen is distended

C

What are the primary nursing considerations when assisting with, or conducting, a physical assessment of the genitalia? a. Ensuring sterility of all equipment and supplies b. Leaving the room during the assessment c. Respecting the client's privacy and modesty d. Providing a means for cleansing the area

C

What independent nursing intervention can be implemented to stimulate appetite? a. Administer prescribed medications b. Assess manifestations of malnutrition c. Encourage or provide oral care d. Recommend dietary supplements

C

What technique should the nurse use to implement infection control in the home? a. Wear gloves at all times when in the home or traveling in the car b. Avoid touching any object in the home, including door knobs c. Practice hand hygiene when beginning and ending the home visit d. Take prescribed antibiotics on a regular basis on working days

C

When assessing a client's vital signs, a nursing student has explained to the client each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce her intention to asses the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information? a. The nurse likely assessed the client's respiratory rate simultaneous when counting heart rate b. Tachypnea is an expected finding among hospitalized individuals c. The client may alter the rate of respiration if the client is aware that his breaths are being counted d. Temperature, pulse, and blood pressure are more volatile that respiratory rate

C

When caring for a client, the nurse gives day-to-day examples to explain certain points of the health education. The nurse also notes the client's concentration level and educates when the client is active. Which category does the client fall into? a. Learning needs b. Motivation c. Attention & concentration d. Learning readiness

C

Which characteristic of a nurse's charting will assist most in the avoidance of errors? a. Subjectivity b. Berevity c. Timeliness d. Detail

C

Which client would be classified as having chronic pain? a. A client with controlled hypertension b. A client with the flu c. A client with rheumatoid arthritis d. A client with pneumonia

C

Which disease may result in decreased lung compliance? a. Appendicitis b. Chronic diarrhea c. Emphysema d. Acne

C

Which intervention are recommended guidelines for meeting client postoperative elimination needs? a. Encourage food and fluid intake when ordered, especially diary products and low-fiber foods b. Assess for bladder distention by palpating below the symphysis pubis if the client has not voided within 8 hours after surgery c. Assess for the return of peristalsis by auscultating bowel sounds every 4 hours when the client is awake d. Assess abdominal distention, especially if bowel sounds are audible or are low pitched

C

Which of the following best describes stress? a. A response to internal environment for homeostasis b. A localized response of a tissue or organ to a stressor c. A response to changes in the normal balanced state d. A perception that something is threatening

C

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a. Encourage the client to alternate between eating and nebulizer treatment during mealtimes b. Encourage the client to eat immediately before breathing treatments c. Provide three large meals daily d. Provide six small meals daily

D

The nurse develops long-term and short-term outcomes for a client admitted with asthma. What is an example of a long-term goal? a. Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear b. Within 1 hour of nebulizer treatment, adventitious breath sounds and cough are decreased c. By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma d. Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack

D

The nurse is caring for a client with a diagnosis of end-stage-renal disease. The client has expressed the desire to be "kept comfortable" and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? a. Persuade the client to agree to the daughter's request b. Contact the imaging center to schedule the testing c. Arrange a meeting between the physician and daughter d. Explain to the daughter the wishes of the client

D

The nurse is caring for a hospice client who states that she is worried about how she has treated a younger sister. She asks the nurse how to make things right. The nurse recognizes this as which spiritual need? a. Love b. Purpose c. Meaning d. Forgiveness

D

The nurse is having an exceptionally busy shift on an obstetrical unit. Which of the following tasks is the nurse justified in delegating to an unlicensed care provider? a. Giving an anti-inflammatory medication to a client who is eight hours postdelivery b. Helping a first-time mother achieve a good latch when breast-feeding her infant c. Assessing the size and quality of clots that are in a client's bedpan and informing the nurse d. Emptying a client's foley catheter bag and reporting the volume to the nurse

D

The nurse is making the bed occupied by a client. What is a recommended step for this procedure? a. Discard soiled linen onto the floor b. Place the drawsheet under the client's knees c. Nurse should lower side rail on the side opposite to her d. Fan-fold soiled linens as close to client as possible

D

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? a. Ask the English-as-a-Second-Language client to state in her or her own words what it means to be NPO b. Request that family members provide ethnic/cultural foods of the African client's liking c. Seek input from the family of how the client with aphasia normally communicates at home d. Respond to the postoperative client's question that baths are given only in the morning

D

The nurse knows that a health care facility should determine its disaster-preparedness plan for delivering care in the event of an emergency or disaster? a. After the first disaster has been experienced b. When officially informed disaster has occurred c. As soon as the disaster is announced publicaly d. In advance of a possible emergency or disaster

D

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurse' own terms. Which documentation format is most likely to promote this goal? a. FOCUS charting b. Charting by exception c. SOAP notes d. Narrative notes

D

The nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which action would be most appropriate for the nurse to do? a. Use a highlighter to mark the incorrect entry and place initials next to it b. Completely erase or delete the erroneous entry if possible c. Block out the erroneous entry with a dark pen or marker d. Strike out the entry with a single line, place initials next to it, and write the correct entry

D

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback? a. Significant differences in the charting between nurses due to lack of standardization b. Increased workload for nurses in order to complete necessary documentation c. Failure to identify and record client problems and associated interventions d. Vulnerability to legal liability since nurse's safe, routine care is not recorded

D

The young nurse has been subjected to unwanted touching and suggestive sexual comments by a nurse of the opposite sex on several occasions. Each time the young nurse has told the other nurse to stop the behavior. What step would not be appropriate for the young nurse to take now? a. Document the behavior, date, and time of each occurrence. b. Read and follow the company's policy about sexual harassment c. Inform the nursing supervisor d. Enlist support from the other nurses working on the unit.

D

What activity is carried out during the implementing step of the nursing process? a. Assessments are made to identify human responses to health problems b. Desired outcomes are evaluated and, if necessary, the plan is modified c. Mutual goals are established and desired client outcomes are determined d. Planned nursing actions (interventions) are carried out

D

Which client care concern is clearly a nursing responsibility? a. Ordering diagnostic examinations b. Performing surgical procedures c. Prescribing medications d. Monitoring health status changes

D

Which client would be most likely to have decreased anxiety about, and response to, pain as a result of past experiences? a. One who had pain but did not get relief b. One who has had chronic pain for years c. One who has had multiple pain experiences d. One who had pain but got adequate relief

D

Which description most accurately defines an infection? a. An illness resulting from living in an unclean environment b. An acute or chronic illness resulting from traumatic injury c. The result of lack of knowledge about food preparation d. A disease resulting from pathogens in or on the body

D

Which of the following nursing care tasks is acceptable for a graduate nurse to delegate to unlicensed assistive personnel? a. Evaluation of nursing care delivered to a client b. Development of a client teaching plan c. Initial and ongoing assessment d. Assisting a client with ambulation

D

Which question asked by the nurse when taking a client's health history would collect data about infection control? a. "Do you sleep well and wake up feeling healthy?" b. "Tell me what you eat in each 24-hour period" c. "What were the causes of death for your family members?" d. "When did you complete your immunizations?"

D

Which statement accurately describes pain experienced by the older adult? a. A heightened pain tolerance occurs in the older adult b. Residents in long-term care facilities have a minimal level of pain c. The older client has decreased sensitivity to pain d. Boredom and depression may affect an older person's perception of pain

D

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which action clearly demonstrates assessing? a. The nurse documenting the incident b. The nurse removing the wash basin c. The nurse bathing the client d. The nurse asking if the client is having pain

D

In which health care setting is a client more likely to be at risk for sensory deprivation? a. Hospital newborn nursery b. Emergency department c. Community health center d. Isolation room in a hospital

D

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? a. Assist in moving to prevent strain on the suture line b. Tell the client that a mild fever is a normal response c. If a scar forms over a joint, it may limit movement d. Administer pain medications on a prn and regular basis

A

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position to help him breathe more easily. Based on understanding that prolonged sitting may put pressure on bony prominence, the nurse frequently assesses which area of the client? a. Sacrum b. Hands c. Elbows d. Back of the skull

A

A nurse is carrying out an order to remove a indwelling urinary catheter. What is the first step of this skill? a. Wash your hands and put on gloves b. Ask the client to take several deep breaths c. Deflate the balloon d. Tell the client burning may initially occur

A

A nurse is educating the client who has congested lungs on how to keep secretions thin and more easily coughed-up and expectorated. What would be one self-care measure to teach? a. Increase oral intake of fluids to 2-3 quarts daily b. Limit oral intake of fluids to less than 500 mL daily c. Take warm baths every night for a week d. Maintain bed rest for at least 3 days

A

A nurse is providing foot care to an elderly client who has diabetes and decreased mobility. What technique would the nurse employ when providing foot care? a. Use an antifungal powder on the client's feet, if necessary b. Avoid using soaps or commercial cleansers whenever possible c. Carefully remove any corns or calluses that are present d. Soak the client's feet for 15-20 minutes in hot water prior to cleansing

A

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse recognizes that which condition is likely affecting the client? a. Orthostatic hypotension b. Anemia c. Thrombophlebitis d. Bradycardia

A

A client asks a nurse to explain a living will. What is the nurse's best answer? a. It lists specific instructions for health care provisions b. It identifies a trusted person to make health care decisions c. It specifies who will inherit the client's estate d. It determines an individual's quality of life

A

A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? a. Oral hygiene b. Hair care c. Chewing gum d. Back rub

A

A client is constipation and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse? a. Stimulates the vagus nerve to decrease the rate b. Left ventricle pumps more forcefully; pulse is stronger c. Stimulates the vagus nerve to increase the rate d. Right ventricle is less efficient; pulse is thready

A

A client is having difficulty having a bowel movement on a bedpan. What is the physiologic reason for this? a. The position does not facilitate downward pressure b. It is painful to sit on the bedpan c. The position encourages the Valsalva maneuver d. The cause is unknown and requires further study

A

A client is on bed rest and an enema has been ordered. In what position should the nurse position the client? a. Sim's b. Fowler's c. Sitting d. Prone

A

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? a. Administer prescribed pain medication 30 minutes before deliberately attempting to cough b. Administer prescribed pain medication just before coughing c. Ask the client to drink plenty of water before coughing d. As the client to lie in a lateral position when coughing

A

A client's PaCO2 is abnormal on ABGs. What is the mostly likely medical diagnosis? a. Chronic obstructive pulmonary disease (COPD) b. Sexually transmitted infection c. Rheumatoid arthritis d. Infection of the ureters and bladder

A

A client's bed partner reports the client has irregular snoring followed and silence followed by a snort. Does this warrant further assessment? a. Yes, this is an indicator of sleep apnea. b. No, this is a description of normal snoring. c. No, snoring has varied patterns. d. Yes, the bed partner is unable to sleep at night.

A

A friend has lost her job and is becoming increasingly anxious to the point of crisis. What type of crisis is she experiencing? a. Situational b. Maturational c. Emotional d. Adventitious

A

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? a. Infection b. Dehiscence c. Evisceration d. Fistula

A

A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care? a. Educate the client about the benefits of early mobilization and offer to assist him b. Respect the client's wishes to remain in his bed and ask him when he would like to begin mobilizing c. Show the client the expected outcomes on his clinical pathway that relate to mobilization d. Document the client's noncompliance and reiterate the consequences of delaying mobilization

A

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? a. "Unable to palpate femoral pulse in left leg" b. "I am so sick; I am about to throw up" c. "Appears anxious and frightened" d. "My leg hurts so bad, I can't stand it"

A

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? a. Orient the client to the room and environment upon admission b. Administer pain medication sparingly in order to minimize any cognitive side effects c. Provide the client with a bedpan to reduce ambulating to the restroom d. Place the client in a shared room with a client who is stable and oriented

A

During a client assessment, the nurse has the client close his eyes. The nurse then places her finger on his right thigh. She asks the client where he is being touched and he answers "my right thigh." This is an example of which sense? a. Olfactory b. Kinesthetic c. Visual d. Auditory

B

Many different factors affect growth and development. For example, who does one child have blond hair and blue eyes while another child has brown hair and green eyes? a. Prenatal influences b. Genetic inheritance c. Maternal nutrition d. Childhood illness

B

Nurses evaluate many aspects of the health care delivery system. What is always the primary concern when performing the evaluating step of the nursing process? a. The nurse b. The client c. The health care system d. The efficiency of the nursing process

B

A child demonstrates increasing language skills and an understanding of symbols. Creative play and the use of imagination is an important activity in the child's life. Based upon these characteristics and according to Jean Piaget's theory, what stage of cognitive development is the child demonstrating? a. Formal Operational Stage b. Preoperation stage c. Concrete Operational Stage d. Sensorimotor stage

B

A client is experiencing hypoxia. What nursing diagnosis would be appropriate? a. Nausea b. Anxiety c. Pain d. Hypothermia

B

A client reports that her naps after lunch often stretch to 3 hours in length and that she has great difficulty arousing herself after a nap. This condition is best termed as which of the following? a. Insomnia b. Hypersomnia c. Parasomnia d. Sleep apnea

B

A client tells a nurse that he does not think he can have the recommended heart surgery because transfusions are against his religion. What is the best response of the nurse in this situation? a. Tell the client that the surgery is necessary to keep him alive and is the only choice b. Obtain all the information needed for the client to make an informed decision c. Prepare the client for a visit from his spiritual advisor d. Have the client sign a form stating his refusal of the treatment

B

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: a. Sanguineous b. Serosanguineous c. Purulent d. Serous

B

A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured? a. Skin surface b. Rectal c. Oral d. Axillary

B

A nurse has seen several clients at a community health center. Which client would be most at risk for developing an infection? a. A middle-age adult with joint pain and stiffness b. An older adult with several chronic illnesses c. An adolescent who had a physical prior to playing basketball d. An infant who has just received first immunizations

B

A nurse id delegating the collection of urinary output to an unlicensed assistive personnel (UAP). What should the nurse tell the UAP to do while measuring urine? a. Tell the client to wash the urethra before voiding b. Wear gloves when holding the client's urine c. Compare the amount of output with intake d. Use a clean measuring cup after each voiding

B

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes the client is having respiratory distress. What should the nurse do next? a. Conduct interview later and let the client rest b. Initiate interventions to help relieve the symptoms c. Continue with the health history, but more slowly d. Ask questions of the family instead of the client

B

A nurse is describing infant care with a woman who has just had a baby girl. What type of nutrition would the nurse recommend for the infant? a. Solid foods after the first month b. Breast feeding or formula with iron c. no solid foods until 1 year of age d. Bottle feeding with cows milk

B

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she be expected to find and document? a. "Colostomy bag intact without feces present" b. "Ileostomy bag half-filled with liquid feces" c. "Ileostomy bag half-filled with hard, formed feces" d. "Colostomy bag filled with flatus and feces"

B

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with this information? a. Ensure the information is included in the nurse's end-of-shift report b. Compare total intake and output of fluids for 24 hours c. Compare the client's intake with the normal range for adult fluid intake d. Report the exact milliliter intake to the physician's office nurse

B

A resident of a long-term care facility refuses to eat until she has had her hair combed and her makeup applied. In this case, what client need should have priority? a. The need to live in a safe environment b. The need to feel good about onself c. The need to have nutrition d. The for need love from others

B

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? a. An infectious agent b. A reservoir c. Portal of entry d. Portal of Exit

B

After a client falls out of bed, the nurse completes which of the following? a. Progress note stating event report was completed b. Safety event report (incident report) c. Malpractice report d. Telephone call to hospital attorney

B

A woman has had a breast removed to treat cancer. What type of loss will she most likely experience? a. Perceived loss b. Anticipatory loss c. Maturational loss d. Actual loss

D

A client age 78 with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? a. Protect the foot from blisters b. Remove ingrown toenails c. Soak the foot in witch hazel d. Cut the nail straight across

D

A client tells the nurse, "Every time I sneeze I wet my pants." What is this type of involuntary escape of urine called? a. Normal micturition b. Urinary incompetence c. Uncontrolled voiding d. Urinary incontinence

D

A client who had a recent below-the-knee amputation reports he feels as if his toes are cramping. What would the nurse say in return? a. "Oh, that is all in your mind, just forget it" b. "Well, that is really strange. I will notify the doctor" c. "I think it might be good to refer you to a psychiatrist? d. "This is called phantom pain and is not unusual"

D

A diabetes nurse educator is teaching a client newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education? a. To implement ordered teaching and counseling b. To facilitate complete recovery from the disease c. To ensure the client will return for follow-up care d. To help with client develop self-care abilities

D

A dietitian is providing an in-service for nurses on a medical-surgical unit. During the in-service the dietitian informs the nurses there are six classes of nutrients, three supply the body with energy. What are the three sources of energy? a. Vitamins, minerals, water b. lipids, vitamins, minerals c. Carbohydrates, protein, water d. Carbohydrates, protein, lipids

D

A dying client and family have requested that no attempts be made to resuscitate the client in the event of death. A doctor has written a DNR order. What is the nurse's responsibility if the client dies? a. Follow his or her own conscience and perform CPR b. If the client is at home, call 911 and begin CPR c. Follow a verbal physician's order for a slow code d. Make no attempt to resuscitate the client

D

A nurse caring for critically ill clients uses interventions to help clients maintain a sense of self. Which of the following are recommended interventions? a. Disregard the client's status b. Do you use touch out of respect for the client's privacy c. Do not acknowledge or allow expression of negative feelings d. Converse with the client about his life

D

A nurse is assessing a client on the first day after major abdominal surgery. Which of the following internal stimuli would be increased and affect client responses? a. Lights and noise b. Visitors and caregivers c. Ambulating, coughing d. Intravenous lines, pain

D

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from unintentional poisoning? a. Closely monitor the toddler's activity b. Do not leave the toddler alone c. Label poisonous solutions d. Keep cleaning solutions locked up

D

A nurse is caring for a young client who is dying of renal failure. What should the nurse do when caring for the dying client's family members? a. Request the family members not to talk about death to the client b. Inform the family that the client may soon be out of danger c. Encourage the family to leave the client to rest quietly without people around d. Inform the family members that it is time to bid farewell to the client

D

A nurse is changing the bed linen of a client admitted to the health care facility. Which isolation precaution should the nurse follow? a. Contact precautions b. Airborne precautions c. Droplet precautions d. Standard precautions

D

A nurse is formulating a nursing diagnosis for a client with respiratory disease. Which nursing diagnosis would be correct? a. "Cough related to ineffective airway clearance" b. "Refuses to cough and expectorate thick mucus" c. "Needs nasal oxygen to improve breathing" d. "Ineffective airway clearance related to thick mucus"

D

A nurse is repositioning a client who has physical limitations due to recent back surgery. The nurse should turn the client in bed every: a. 4 hours b. shift c. Hour d. 2 hour

D

A nurse visits a diabetic client age 60 years in his home after the client's above-the-knee amputation of his left leg. The client appears disheveled and with poor hygiene. He also avoids making eye contact with the nurse. What is likely to occur as a result of the client's reduced self-esteem? a. Lack of interest b. Withdrawal c. Lethargy d. Self-care deficit

D

A school nurse is educating a class of middle-school age girls on maintaining urinary system health. What statement by one of the girls indicates a need for more information? a. "I will take showers rather than baths" b. "I will wear underpants with cotton crotches" c. "I will tell my parents if I have burning or pain" d. "I will wipe back to front after going to the toilet"

D