PCC EXAM 1 review questions&book questions

What nursing action should be used for a client with pneumonia of the right lower lobe?

Place the client on the left side and elevate the foot of the bed.

Which reported behavior by a parent of a 4-month-old infant indicates the need for further teaching?

Warming formula in the microwave (because it can cause burns)

The nurse is inserting an intravenous catheter into a client. Blood drips down from the venipuncture and lands on the nurse's arm. Which intervention should the nurse perform first?

Wash the affected area thoroughly

A registered nurse (RN) is interviewing for a new staff position at a hospital and asks about staffing and client assignments. The interviewer explains nurses work in a functional nursing role. Which statement best explains this approach?

RNs provide compartmentalized care, perform complex treatments, and are in charge

Which is the most accurate method of verifying correct feeding tube placement when a tube is initially placed?

Radiography

A teen comes to the emergency department (ER) with ankle pain after a soccer injury. The provider determines that the teen has experienced stretching of a ligament that has caused the ligament to tear. How should the nurse document this finding?

Sprain

The 6 types of staging of a pressure injury.

Stage 1, Stage 2, Stage 3, Stage 4 Unstageable Deep tissue

Review each stage of Benner's model of skill and judgment acquisition. Place in the correct sequential order.

Stages order: Novice Advanced Beginner Competence Proficient

What is the most common cause of infectious pharyngitis?

Streptococcal pyogenes. (Streptococcal pyogenes is the most common cause of infectious pharyngitis, otherwise known as "strep throat.")

5 positioning techniques for bed bound patients.

Supine Prone High Fowlers Lateral Trendelenburg (reverse Trendelenburg)

When inserting an indwelling catheter, which level of asepsis is used?

Surgical Asepsis

How would a nurse best describe a glomerular filtration rate?

The amount of filtrate formed by the kidneys per minute

The nurse answers a call light and sees this client in bed. What assumptions can be made by the nurse about the risk of immobility from the device being used?

The client is at risk for hip abduction

Common causes of wound dehiscence?

infection, obesity, coughing, sneezing, any thing that causes inter-abdominal pressure to increase. abdominal surgery are more at risk

When teaching a client how to use a peak flow meter at home, what should be done if the reading falls within the yellow marker of the meter?

Use a fast-acting bronchodilator.

Which are interventions used to manage and minimize the symptoms of dry mouth? Select all that apply.

Use hard candy or gum. Take frequent sips of water. Use lip moisturizer.

A client is encouraged to use isotonic muscle strengthening. Which recommendations should the nurse give to achieve this?

Use of free weights

What healthcare setting has the highest acuity?

inpatient settings

What is the treatment for a wound that eviscerates?

keep moist, call surgeon, keep patient flat with the knees up

What diet would be for patients with chewing difficulty, missing teeth?

mechanical soft diet

What are 5 types of diets for long term use?

mechanical soft diet diabetic diet low fat diet general diet low sodium diet

3 risk factors for patients at risk of falling.

older age previous history of falls medications: opiates, (#1) psycortropics, diuretics

Which factors control the growth of microorganisms? Select all that apply.

pH, Light, Oxygen, Temperature

What step in the nursing process is the expected outcome?

planning step

Signs and symptoms of orthostatic hypotension.

posture changes, drop in BP, dizziness, faint, pulse could rise

What type of isolation is used if the patient is at risk of infection?

protective isolation/reverse isolation

What color on the peak flow meter represents a patient with asthma is less than 50% of their personal best baseline?

red

4 types of healing wounds.

regeneration primary secondary tertiary

A nurse is caring for a client a few hours after admission. The client points out a new rash on their arms and abdomen that itches. The nurse observes this. What action should the nurse take next?

review the medication list

The nurse is performing an assessment of a client's body fat content. Which information would best determine this?

skinfold measurements

Why did the National Council of State Board of Nursing create CJM model?

to ensure safety and check that nursing graduates have clinical reasoning and critical thinking skills to make safe decisions regarding patients

What position would a patient with COPD be in to breath easier?

tripod position/ orthopneic

Movement of air into and out of the lungs through the act of breathing is called.......

ventilation

Which are nutrients that are inorganic elements found in nature?

Minerals

What type of PPE shoulda nurse wear when a patient is under airborne precautions?

N-95 mask, gloves, face shield, gown

What organization is responsible for setting and maintaining nursing educational standard?

National League for Nursing (NLN)

What are the 5 types of WBCs measured in a CBC with differential?

Neutrophils. Lymphocytes Monocytes. Eosinophils. Basophils

Which type of evaluation is performed immediately after an intervention and with each client contact?

Ongoing evaluation

A nurse who is obtaining a health history through an interview asks, "What can you tell me about your previous knee replacement surgery?" Which type of question is this?

Open-ended (this encourages discussion and further exploration)

Which factor most decreases adverse outcomes in a healthcare facility?

Quality nursing care

What is RACE used during a fire in a patient room?

R- rescue A- activate alarm C- contain fire E- extinguish fire

Which structures are contained within a nephron? Select all that apply.

Collecting duct Bowman's capsule Filtrating tubules

What are the finding in a urinalysis that indicate probable UTI?

Leukocyte esterase, nitrites, bacteria, red blood cells (RBC)

Which of the nurse's questions demonstrates critical thinking?

"Have I gathered enough data to make a decision?"

The nurse is educating a group of clients about risks for food poisoning. Which statement made by a client indicates understanding?

"I should not consume cookie dough"

Which statement best reflects a critical-thinking philosophy?

"Think about different interventions that can be used with this client"

what are 3 things that should be included in the diet of a postoperative patient?

-clear liquids to soft foods (progressive diet) -protein, zinc, vitamins A and C

Place the anatomical structures in the order in which blood is filtered.

1- The kidneys contain nephrons, which perform filtration of blood and forms urine 2- Urine is carried from the kidneys to the bladder through the ureters.Correct Position: 2 3- Urine from the ureters is stored in the bladder 4- The urinary meatus is the way in which urine leaves the body

A client is given a diagnosis of terminal cancer, and the healthcare provider suggests hospice services for the family. The family is hesitant and asks the nurse what hospice can provide. Which responses given by the nurse are appropriate? Select all that apply.

1) "Hospice services ensure the client is comfortable and the pain is controlled" 2) "Hospice services allow client to preserve dignity during the dying process" 3) "Hospice services provide spiritual care for the client within the client's culture"

The nurse is differentiating between a medical diagnosis and a collaborative problem. Which statements are correct? Select all that apply.

1) A medical diagnosis describes an illness or injury 2) A medical diagnosis identifies pathology 3) A collaborative problem is determined by a medical diagnosis 4) A collaborative problem is managed by both medical and nursing interventions

Which statements represent a measurable outcome? Select all that apply.

1) Demonstrate correct method for checking blood sugar by next visit 2) Will have bowel movement within 12hrs after receiving stool softener and laxative 3) Calls nurse when urge to defecate is felt; does not delay defecation

Which describes components of implementation in the nursing process? Select all that apply.

1) Doing 2) Delegating 3)Documenting

The nurse is caring for a client who is being treated for pneumonia and develops clostridium difficile from the antibiotic therapy. The client is placed on contact precautions. What interventions should the nurse perform? Select all that apply.

1) Double bag all trash and label it as contaminated 2) Provide disposable blood pressure cuff, thermometer, and stethoscope

A nurse is working at a clinic and wants to focus on primary healthcare in the community. Which interventions would be included in the nurse's plan? Select all that apply.

1) Educating children on appropriate hand hygiene 2) Administering flu shots to elderly clients in independent living center 3) Presenting information at a senior center regarding ways to prevent diabetes mellitus

Which are examples of a direct-care nursing intervention? Select all that apply.

1) Giving medication 2) Obtaining vital signs 3) Giving a bedside bath

Which are tools for recording assessment data? Select all that apply.

1) Graphic flow sheet (things like vital signs to identify trends) 2) Intake and output sheet

The nurse is teaching a client about a variety of complementary and alternative therapies. Which options could the nurse include with the discussion? Select all that apply.

1) Naturopathy 2) Homeopathy 3) Chiropractic medicine 4) Traditional Chinese medicine

Analyzing a client's temperature changes and assessing for signs of infection

1) Need to find the truth 2) Openness to other options 3) Use of reasoned thinking 4) Capacity to reflect on situations

Which are the common responsibilities of the state boards of nursing? Select all that apply.

1) Providing approval for nursing education programs 2) Enforcing rules that govern nursing practice 3) Developing criteria that permit someone to be licensed as an RN or as a licensed practical or vocational nurse (LPN/LVN)

The home-health nurse is instructing the family of an older adult client about safety precautions that should be taken in the bathroom. Which information should the nurse provide? Select all that apply.

1- Used raised toilet seats 2- Set up grab bars in the shower 3- Purchase a sturdy shower chair for the client

The U.S. Department of Health and Human Services (USDHHS) is working to reduce which healthcare-related infections? Select all that apply.

1) Surgical site infections 2) Multidrug resistant organisms 3) Ventilator-associated pneumonia 4) Catheter-associated urinary tract infections

The healthcare team is determining discharge plans for a client admitted after involvement in a motor vehicle accident. The client requires intravenous antibiotics, as well as physical and occupational therapy, and wants to receive these services in the home. Which factors determine if this is appropriate? Select all that apply.

1) The presence of help in the client's home 2) The coverage provided by the clients insurance carrier 3) The availability of a home healthcare agency to provide the required services

Which critical-thinking skills will a nurse utilize when reviewing the health record of a new client to prepare a nursing diagnosis? Select all that apply.

1) Visualizing potential solutions to a problem 2) Prioritizing or ranking data as needed 3) Separating relevant from irrelevant data

A nurse is providing care for several clients in a large medical center. When delivering medications, the nurse scans the bar code on the medication package and the client's identification band comparing the information to the electronic health record. The computer has a pop-up message that there is a drug interaction. The nurse contacts the hospital pharmacy. Which of the Institute of Medicine's competencies are addressed with this event? Select all that apply.

1) Work in inter professional teams 2) Employ evidence-based practice 3)Apply quality improvement 4) Utilize informatics

Which interventions can the nurse include in the plan of care to reduce a client's feeling of isolation related to being on transmission-based precautions? Select all that apply.

1)Allow electronics in their room 2)Schedule time to spend with patient 3)Instruct family members on transmission-based precautions to allow visits

The nurse is working with an older adult client and designs a care plan to reduce the risk of infection. Which nursing interventions should the nurse include? Select all that apply.

1)Keep the skin clean and dry 2)Offer foods high in protein

Which statements are accurate regarding normal flora? Select all that apply.

1)Normal flora synthesize vitamin K 2)Normal flora aid in the digestive process 3)Normal flora release B vitamins when they die

Which factors determine if a client will develop an infection? Select all that apply.

1)Quantity of organisms 2)Virulence of the organisms 3) Ability to survive in the host 4) Host's ability to fight off infection

Which nursing interventions are important for the home-health nurse to perform to promote safety when caring for older adult clients? Select all that apply.

1)Removing throw rugs, 2)moving electrical cords, 3)changing positions slowly, 4)using visual and hearing aids

Which circumstances would qualify a client for a move into an independent living center? Select all that apply.

1)The client must be over the age of 55 2) The client must be autonomous in all activities of daily living (ADLs) 3) The client must have a desire to live with senior citizens

Which factors lead to increased numbers of injuries in children and younger adults related to motor vehicle accidents? Select all that apply.

1- Driver distraction 2-Failure to use seatbelts 3-Improperly placed car seats

The nurse enters the room of a client to perform wound care and administer medications. When should the nurse apply clean gloves? Select all that apply.

1- During medication administration 2- Prior to removing soiled dressings 3- Before treating a new patient

The nurse in a long-term care facility is caring for a 70-year-old client who has a history of type 2 diabetes mellitus, hypertension, and Parkinson disease. The client takes antihypertensive medications, insulin, and carbidopa/levodopa. The client has functional incontinence due to a shuffling gait and uses a wheeled walker for ambulation. Which factors place the client at risk for falls? Select all that apply.

1- Parkinson disease 2- Wheeled walker use 3- Functional incontinence 4- Antihypertensive medications

List in order the steps for handwashing:

1- Push sleeves above wrists 2- Turn on water 3-Wet hands and all arm surfaces 4-Apply soap and rub hands together 5-Clean under fingernails 6-Rinse hands 7-Dry hands 8-Turn off water with paper towel

The nurse is educating the parents of a toddler about medication safety in the home. What should the nurse include in the teaching plan? Select all that apply.

1- Refrain from calling medications "candy" 2- Avoid taking medications in front of children 3- Store all medications in child resistant containers

What is the correct procedure for responding to small fires? (In order 1-4)

1- Rescue the clients 2- Activate the alarm 3- Confine the fire 4- Extinguish the fire

Which criteria must be present for an occurrence to be labeled a never event? Select all that apply.

1- Serious 2- Preventable 3- Measurable

Place the steps for performing a tracheostomy or endotracheal suctioning in order.

1-Assess the client's respiratory status, position in semi-Fowler's, and place linen-saver padding on the client's chest 2-Don face shield/goggles and turn on suction using the lowest pressure 3-Don nonsterile gloves and test the suction. 4-Remove and discard gloves; then open the suction catheter kit 5-Don gloves. Pour sterile saline into the sterile container 6-Premeasure the catheter insertion distance 7-Don sterile gloves. Attach the suction catheter to the connection tubing 8-placing the tip of the catheter in the sterile saline, suction a small amount of solution through the catheter 9-Lubricate the suction catheter tip with normal saline solution. 10-Gently and quickly insert the suction catheter into tubing and apply suctioning. 11-Perform hand hygiene, then perform mouth care for the client

An individual has recently moved from the coast of Florida to the Rocky Mountains in Colorado. What physiological changes will occur over time to facilitate oxygenation? Select all that apply.

1-Increased RBC production 2-Increased lung volume and pulmonary vasculature 3-Increased ventilation 4-Arterial chemoreceptors stimulate ventilation

The 5 steps of the Nursing Process.

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

What is the ranking of the following 4 Nursing Diagnoses according to Maslow's hierarchy? nutrition deficit, pain, risk for falls, chronic low self-esteem

1. risk for falls 2. pain 3. nutrition deficit 4. chronic low self-esteem

Which specific gravity would the nurse document as normal?

1.02 (normal is 1.002 to 1.030)

Place the steps of the nursing process in the correct order:

1: Assessment 2: Diagnosis 3: Planning 4:Implementation 5: Evaluation (ADPIE Acronym helps remember the order)

What is a normal White Blood Cell count (WBC)?

5,000 to 10,000 wbc count

What is a normal blood glucose level?

70-100 mg/dL

Which client would the nurse consider to be at the highest risk of developing a nosocomial infection? (Nosocomial infections also referred to as healthcare-associated infections (HAI), are infection(s) acquired during the process of receiving health care that was not present during the time of admission.)

A 65-year old client with an indwelling urinary catheter

Which is the best example of intellectual courage?

A nurse fairly examines their own values and beliefs even when uncomfortable

Which nurse would fall into Benner's stage of being an expert nurse?

A nurse who assesses a client, believes that something is not right, and notifies the healthcare provider

A nurse is assisting a client to a standing position. The client requires frequent breaks and feels short of breath. After standing for a few seconds, the client states exhaustion and needs to lie down again. What should the nurse include in the plan of care?

Activity intolerance

An individual begins gasping for air and makes an unusual high-pitched, harsh, crowing sound. What could be occurring?

Airway obstruction

What is the cognitive overload that nurses may experience because of an overwhelming number of alarm sounds?

Alarm Fatigue

A client has been brought in from a motorcycle accident and suffered deep track-like injuries with debris that can be only partially removed. What type of dressing should be applied to this client's wounds?

Alginate

Which action made by the nurse indicates the use of clinical judgment?

Analyzing a client's temperature changes and assessing for signs of infection

The nurse enters a client's room to obtain a fasting blood glucose reading and notices the breakfast tray is in front of the client. Which action best indicates the nurse using critical thinking?

Asking the client if they have eaten any food yet

The 6 steps of the Clinical Judgement Measure Model (CJM), as it relates to the nursing process.

Assessment: Recognize Cues. Diagnosis: Analyze Cues. Planning: Prioritize Hypotheses, Generate Solutions. Implementation: Take Action. Evaluation: Evaluate Outcomes.

The client expresses a desire to lose weight. An increase in which of these will best achieve that?

Basal metabolic rate (the measure of energy used when a body is neutral and at rest)

A registered nurse (RN) is developing a plan of care for a client admitted with pneumonia. Which tasks can the RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Bathing the client, Taking the vital signs, Telling the nurse about an open area on the skin

According to Leapfrog Hospital Safety Grade (2019), approximately how many avoidable deaths occur in U.S. hospitals each year?

Between 100,000 to 200,000

How is the CUS method used to speak up for safety?

C- concerned U- uncomfortable S- safety issue

Which is an advantage of intermittent catheterization over indwelling catheters?

Can be removed immediately and client can void normally

Which metabolic process breaks larger particles into smaller ones and releases energy?

Catabolism

What are the 4 types of UTI's?

Catheter Associated Urinary Tract Infection(CAUTI) Pyelonephritis(bladder) Cystitis Urethritis(urethra)

Which structures of the central nervous system are involved in physical coordination? Select all that apply.

Cerebral cortex, cerebellum, basal ganglia

The nurse is caring for a male client who is in a prone position. Which locations are at the highest risk for pressure injury?

Cheek and ear Genitalia Toes

A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe?

Clean-catch specimen

A nurse receives an order to deliver a unit of blood if the client's hemoglobin falls below 7.0 g/dL. The nurse enters the room to obtain consent and the client says, "I choose not to take blood; it's not supported by my religion." The nurse makes a note and does not deliver the blood. Which aspect of critical thinking is this nurse using to guide client care?

Client's culture

The nurse is caring for a client experiencing pain and is concerned about the client's oxygenation. Why is this concerning to the nurse?

Clients in pain tend to breathe shallowly, which increases the risk for atelectasis.

What two concepts does clinical judgement include?

Clinical reasoning and critical thinking

What are 3 symptoms a patient might report if a UTI is suspected?

Cloudy urine, pain/burning while urinating, urgency/frequency of urination

What are some roles of a nurse?

Collaborator, communicator, advocate, leader, researcher, healthcare provider

Which areas of healthcare are regulated by legislation? Select all that apply.

Confidentiality of client's records

Which part of the kidney is made up of millions of functional units called nephrons?

Cortex

When checking on a postoperative client, the nurse notices evisceration. What action should the nurse take?

Cover the wound with sterile towels or dressings soaked in sterile saline solution.

A client presents to the emergency department with nausea and vomiting for 2 days and has not urinated for the past 8 hours. Which is the most likely cause of lack of urine output?

Dehydration

Which safety precaution should the nurse take when preparing to administer an injection to a client?

Disposing the needle immediately in the sharps container

What priority concern should the nurse have for a client who has had a stroke and has left-sided hemiparesis?

Disuse syndrome (this is the appropriate diagnosis for this situation)

At which point during hospitalization should discharge planning begin?

During Initial Assessment

Where do you place a sensor probe to obtain a pulse oximeter reading if patient has acrylic nails?

Ear lobe, toe, or put oximeter on the finger sideways

Which phase of wound healing describes collagen fibers breaking down and remodeling?

Epithelialization

The nurse is caring for a client with a chronic cough and shortness of breath. The client denies smoking but lives in "a house of smokers." What should the nurse include when teaching the client? Select all that apply.

Even small amounts of smoke cause damage to the vessels and abnormal heart rate. Secondhand smoke leads to increased risk for stroke and increased death from cancer. There is no safe level of exposure to secondhand smoke. Smoke inhalation can lead to emphysema and chronic obstructive pulmonary disease (COPD).

The nurse is caring for a client who is obese and is returning from an abdominal surgery. What action should the nurse take to prevent dehiscence of the wound?

Maintain bedrest with the head of the bed elevated at 20° and the knees flexed.

How should the nurse plan to move a client who is obese and immobile?

Mechanical lift

Which describes the body breaking down nutrients into chemical energy and then into usable energy?

Metabolism

Gas exchange that occurs in the alveoli-capillary membrane is referred to as what type of respiration?

External (External respiration occurs between the alveoli and capillaries where oxygen and carbon dioxide exchange occurs)

An older adult client is thinking about several treatment options for a new diagnosis of cancer. The client's family is strongly encouraging the client to take the most aggressive medications despite the client's hesitation. The nurse is asked to provide an opinion. Which critical-thinking attitude should the nurse present?

Fair-mindedness

What are primary causes of maceration? Select all that apply.

Fever Incontinence

Which are considered secondary defenses? Select all that apply.

Fever, Phagocytosis, Inflammation, Complete cascade

Which describes a person's ability to carry out activities of daily living (ADLs) without undue fatigue, and with enough energy for leisure pursuits or to respond to emergencies?

Fitness

2 locations of pain and tenderness that a patient may report that signal pyelonephritis?

Flank (lower back) pain CVA (costovertebral angle) terminal

Which type of assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected?

Focused (A focused assessment is directed at a specific complaint or possible problem)

Which are included as part of the U.S. Department of Agriculture (USDA) dietary guidelines? Select all that apply.

Food safety Adequate exercise Choosing a nutritious diet

The nurse uses this device to determine the status of a child with asthma. What is the nurse evaluating?

Forced exhaled air

A client is given the instructions to avoid eating before bedtime, keep the head of the bed elevated at 30 to 40 degrees, and to avoid fatty foods, chocolate, and smoking. Which impaired digestive function is most likely for this client?

Gastroesophageal reflux

The nurse is assessing a client with this drainage system. What is an anticipated finding in the suction control chamber?

Gentle bubbling of water

The nurse performs an assessment on a client with joint inflammation, pain with movement, and high levels of uric acid in the blood. What condition should be considered?

Gout (this is a common form of inflammatory arthritis, and is very painful)

Peak Flow Meter Levels

Green: baseline Yellow: a little trouble breathing Red: less than 50% of the personal best baseline

What is the single most important way to prevent the spread of infection?

Handwashing

What findings should a nurse expect to see if a client has impaired renal function? Select all that apply.

High blood pressure Altered mental status Fluid retention

A client presents to the clinic with a cough. What should the nurse include in the assessment? Select all that apply.

If it is dry, productive, or hacking When it occurs How long the client has had cough Rationale: The nurse should ask how long the client has had the cough. What makes it worse or better Rationale: The nurse should ask about anything that helps or worsens the cough. If there is a fever Rationale: Assessing for fever is important but is not particular to a type of cough. If there has been any irritant exposure Rationale: Irritant exposure such as environmental factors and occupational debris are contributing factors to a type of cough. Question ID:NURS3-OE-9 Course Topic:Oxygenation Concept:Assessment, Oxygenation Cognitive:Analysis [Analyzing] Difficulty Level:Moderate Client Need:Physiological Integrity Chapter:Chapter 33: Oxygenation Page Reference:pp. 1397-1398

What skin-integrity issue should the nurse assess for when working with a client diagnosed with Alzheimers disease?

Impaired cognition can lead to pressure injuries. (Clients with cognitive disorders may not be aware of the need to reposition and thus are predisposed to increased pressure injuries.)

A nurse is working in a healthcare facility with a protocol stipulating that clients with pneumonia should turn, cough, and deep breathe. This nurse is assigned to care for a client admitted with pneumonia but does not encourage the client to cough because the client also has esophageal varices from cirrhosis. Which aspect of critical thinking is this nurse using to guide client care?

Individual differences

Which of the following best demonstrate nurses' critical-thinking skills?

Individualized patient care plans

The nurse is monitoring a wound for healing. At which stage of healing would dehiscence typically be seen?

Inflammatory phase

A client presents with cyanosis, tachypnea, and grunting, and reports having difficulty breathing. What is the immediate action the nurse should take?

Inspect to observe respiratory patterns and signs of respiratory distress.

A nurse with several years of experience in the intensive care unit obtains a new job in the newborn nursery at the healthcare facility. Which critical-thinking attitude would be best for the nurse to employ in this new setting when asking for guidance?

Intellectual humility

A nurse is ambulating a client in the hallway who says, "I feel a little dizzy." The nurse immediately grabs a chair and slides it behind the client, having him sit down. According to Tanner's Model of Clinical Judgment, which reasoning skill is the nurse using after hearing this statement?

Intuitive reasoning

What skin condition should the nurse monitor in a client who is taking blood pressure medication?

Ischemia

What layer of the CJM model has the nurse making decisions to meet patient needs?

Layer 0

Which are urinary symptoms that may occur as a result of the aging process? Select all that apply.

Leakage of urine Nocturnal frequency of urine Bladder infections

During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this?

Objective Data

Which development-related safety issue should the nurse include when educating the parents of a 6-month-old infant?

Objects being placed in mouth

Which nursing action is part of the evaluation phase when performing wound care for a client?

Obtaining wound measurements once a week

Which is the most prevalent type of degenerative disease that can severely limit a person's ability to perform physical activity?

Osteoarthritis

How to evaluate for evidence-based practice.

P- population I- intervention C- comparison O- outcome T- time

How can the nurse best describe the attachment of a muscle to a more stable bone?

Point of origin

The nurse on the medical-surgical unit has noticed a client has edema. What is the nurse's greatest concern?

Poor oxygen diffusion to the cells can cause skin breakdown.

The nurse is preparing to ambulate a client. What is the purpose of applying these slippers prior to having the client get out of bed?

Prevent falls

Which are goals of nursing care for a client with an indwelling urinary catheter? Select all that apply.

Prevent infection. Maintain skin integrity. Maintain the free flow of urine.

Which condition in older men can result in impaired flow of urine from the bladder into the urethra?

Prostatic hypertrophy

What are the goals of infection prevention and control in healthcare? Select all that apply.

Protect clients from contagions Lower the cost of healthcare services Meet professional standards and guidelines Protect employees from contracting infections

A client says to the nurse, "I hate fat. I wonder why the body has it. It serves no purpose!" Which are functions of body fat that the nurse should explain? Select all that apply.

Protection of vital organs Essential to cell metabolism Enables nerve-impulse transmission

The nurse is caring for a client with a large leg wound. An increase in which nutrients are most important to repair and maintain the cells?

Proteins

Which nursing action reflects the nurse assisting the client in maintaining belief as a component of caring?

Providing encouragement to a client with a new amputation

What anatomical feature makes women more prone to urinary tract infections than men?

Proximity of the urethra to the vagina and anus

According to the Institute of Medicine, which competency best promotes the concept of providing safe, quality client care?

Quality Improvement

6 layers of the Clinical Judgement Measure Model, CJM

Recognize Cues. Analyze Cues. Prioritize Hypotheses Generate Solutions. Take Action. Evaluate Outcomes.

A nurse is teaching a client about balanced nutrition. Which reference should the nurse provide for the need for vitamins, minerals, proteins, and total calories?

Recommended Daily Allowance

Which healthcare setting would the registered nurse recommend for a client who needs further inpatient therapy after sustaining a stroke?

Rehabilitation Center

Which actions occur to blood as it moves through the peritubular capillaries? Select all that apply.

Removes ammonia from blood Hydrogen ions secreted to help maintain normal blood pH Removes creatinine from the blood

Premature babies are at higher risk for what respiratory problem?

Respiratory distress syndrome (Due to an undeveloped alveolar surfactant system, premature babies are at higher risk for developing respiratory distress syndrome (RDS).)

What are the 5 rights of delegation the nurse should follow to delegate patient care?

Right task Right person Right communication Right supervision Right circumstance

The nurse is transferring a client to bed upon admission. Which position should the nurse place the client in before beginning a physical assessment?

Semi-Fowler's position. (Semi-Fowler's position involves the client lying on their back with the head of the bed elevated to 30°)

Which professional nursing organization would a nurse seek to join if interested in nursing research and scholarship?

Sigma Theta Tau International (STTI)

Which describe types of muscle? Select all that apply.

Skeletal, Smooth, and Cardiac

A client informs the healthcare provider of increased fatigue upon return from a camping trip last weekend. What would be important to assess for this client?

Skin for bug bites (many vector borne illnesses happen from this)

A client has a wound that has been allowed to heal through secondary intention due to excessive loss of tissue. What would be an anticipated assessment finding as the wound begins to heal?

Small pearl-like or pink areas beginning to appear

A client with heart disease and hypertension should limit which mineral?

Sodium

Which are functions of water in the body? Select all that apply.

Solvent, Lubricant, Carries oxygen, body structure and form

If a person makes a conscious decision to bend the elbow, which nervous system is applied?

Somatic nervous system

The nurse is writing goals for a client's plan of care. What should be considered?

The goals reflect realistic client changes that the nurse hopes to achieve

Which description best describes a modified sterile technique?

The use of nonsterile procedure gloves with sterile supplies

The nurse is reviewing the wound culture report of a client with a Stage 3 pressure ulcer. The report says that the bacteria count exceeds 100,000 organisms per gram of tissue. What assumption can the nurse make about the wound?

The wound is infected.

The 4 kinds of nursing knowledge.

Theoretical Practical Self Ethical

What is the primary purpose of swaddling a newborn for the first few weeks of life?

Thermoregulation

Which statement is correct about the model in this image? (The Clinical Judgment Measurement Model which helps recognize, analyze, organize, prioritize, and use knowledge to make safe client care decisions)

This measures wether a test taker has the established degree of clinical judgment and decision-making abilities to be a safe practitioner

Which chronic conditions impact a client's nutritional needs? Select all that apply.

Traumatic injury Alcoholism Bowel inflammation Cognitive function

What test involves a sterile urine sample to rule out UTI?

Urine culture and sensitivity (CNS)

Which of the following assessment findings would help confirm a diagnosis of asthma in a client?

Wheezing on inspiration and expiration

The nurse is applying good body mechanics while assisting clients. What is being included? Select all that apply.

Wide base of support, Abdominal muscle tight, Chest high

The nurse is performing a skin assessment on an older adult client and notices that there are areas of red, dry, scaly, and cracked skin. The client tells the nurse that it itches. How should the nurse document this finding?

Xerosis

What oxygen device can be given at 5-10 ml/min and delivers oxygen into a clear flexible mask that covers the nose and mouth?

a standard facemask

What are 3 interventions to prevent a patient from falling?

bed alarm, nonslip socks, fall risk assessment(identify them as a fall risk)

What is a noninvasive intervention for patient who is unable to void after surgery?

bladder scanner, to see what amount patient is not able to void

3 types of mechanical aides for walking.

canes, cruches, walkers

3 effects of prolonged immobility on the respiratory system.

decreased respiration pneumonia atelectasis

What are 5 risk factors for a patient to develop a pressure injury?

dehydration immobility(staying in one position too long) skin frailty poor nutrition old age

3 modes of transmission of infection.

droplet contact airborne

What is the purpose of the NCLEX-RN exam?

ensures nurses are tested on safety, main goal is to protect the public

What step in the nursing process dose the nurse judge how well the intervention worked?

evaluation

3 devices used to transfer an immobile patient out of bed?

gait belt, mechanical lift, transfer board

What order is correct when doffing mask, gloves, shoe covers, gown.

gloves, gown, mask, shoe covers

What type of connective tissue has an abundant blood supply?

granulation tissue

What is the best way to verify placement of a feeding tube?

x-ray