Nursing fundamentals final

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?

The client's most recent temperature

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

Include the client and the client's power of attorney in the discussion

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met?

"I walk daily wearing low-heeled shoes.

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate?

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700

Which practice is a correct application of infection control practices?

A nurse performs hand washing each time the nurse removes a pair of gloves.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection?

Client receiving chemotherapy

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use?

Palpate one artery at a time

Which scenario is the best example of a nurse implementing care according to the ANA standards of practice?

Providing nutrition teaching to a client with diabetes

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite.

The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated?

Science of nursing

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse?

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume

The nurse and a student are discussing entry into the profession of nursing. Which statement should the nurse use to describe a diploma program?

"It is obtained by a 24-month program at a hospital."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known."

Which is an example of a psychomotor outcome

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

art of nursing

During World War II, nurses were actively recruited and enlisted in the military. What effect did this have on the nursing profession?

caused a civilian nursing shortage

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client?

droplet

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?

30 to 60 breaths/min

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action?

Auscultate the client's apical heart rate.

The nurse is discussing the recommended entry level for professional nursing practices. Which is the most accurate statement by the nurse?

BSN is the recommended entry level by national nursing organizations

The nurse is conducting a class for nursing assistants. One of the students asks the nurse why blood pressure, pulse, and temperature are called "vital signs." Which explanations would the nurse offer the student?

Because significant deviation from normal is not compatible with life.

A registered nurse plans to return to the nursing profession after a long hiatus. Which statement about the trend in health care services would be most important for the nurse to keep in mind?

Clients enter the health care system acutely ill.

A long-term care facility is seeking an advanced practice nurse to educate the staff regarding palliative care for the residents. The facility would benefit most by hiring which advanced practice nurse?

Clinical nurse specialist

Which nursing activities will be most effective to help achieve the Healthy People 2020 guideline to eliminate health disparities among clients

Conducting blood pressure screenings in an undeserved area

Which scenario is the best example of the nurse implementing the ANA standard relating to diagnosis?

Determining a client is at risk for falls

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?

Encourage hourly use of the incentive spirometer.

Which nursing actions are characteristic of the nurse's role as communicator?

Establishing and maintaining helping relationships with clients of all ages in a variety of settings

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Colostrum difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?

Exogenous healthcare-associated

The nurse is caring for a postpartum mother who delivered her second child yesterday. The mother states that her older child has just been diagnosed with chickenpox. She is concerned that her newborn will develop the disease. What is the best response by the nurse?

Have you had chickenpox?

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?

I can leave my room any time I want as long as I wear a mask.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing

Intervention

Which individual provided community-based care and founded public health nursing?

Lillian Wald

Attracting minorities to the profession of nursing is an important consideration for the future of nursing. Which key historical nursing figure set a precedent in this area?

Mary Eliza Mahoney

The nurse understands that for nursing to be considered a profession, many things need to be in place. Which element is not part of those considerations?

Multidisciplinary approach

A nurse is thinking about pursuing a master's degree in nursing (MSN) and is reviewing information about various programs. What would the nurse expect to find about such programs?

Nurses pursuing such programs require solid scholastic abilities.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

The nurse is caring for a client with a latex sensitivity. Which resource would be most appropriate for the nurse to access when developing the client's plan of care?

Policy for clients with latex sensitivity

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as?

Rationale

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Which should be documented by the nurse?

The fact that sterile technique was used for a given procedure

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?

The first faint, but clear, sound appears.

Which nurse is demonstrating a type of nursing whose roots go back to the ancient Greek times when temples were the center of nursing care?

The nurse conducting a blood pressure screening at a local church

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

keeping sterile field above waist level

Due to the rising cost of health care services, many procedures and treatments are being delivered in what type of setting?

outpatient facilities

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

Which term indicates a potentially serious client condition?

pyrexia

Which is the best example of a nurse demonstrating the role of caregiver?

starting an intravenous line in the client's arm

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?

"The way you are doing it helps to minimize contamination of the non-waterproof side

An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?

Perform surgical hand scrub using detergent.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

The nurse places the client in a private room with monitored negative air pressure.

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?

Wearing an N95 respirator is critical when I care for clients in droplet precautions.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

has manicured nails that are 1-in. (2.5-cm) long

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse?

pouring the sterile solution from a height of 5 in. (13 cm)

Which factor has contributed to resistant microbial strains?

use of antibiotics in clients with viral infections

A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client?

wearing a mask when working within 3 feet (1 m) of the client