Practice (NCLEX) Multiple Choice Questions

The nurse is providing eduction on childhood safety to a group of parents. In response to a question, the nurse relates that the major causes of death in toddlers include which of the following? [Select all that apply.] A. Infections B. Childhood diseases C. Drowning D. Motor vehicle crashes E. Accidents

C. Drowning D. Motor vehicle crashes E. Accidents

A client has sought care because of insomnia that has been increasing in severity and frequency in recent months. What questions should the nurse include in an assessment of this client's health problem? [Select all that apply.] A. "Do you smoke?" B. "Do you have a family history of sleep disturbances?" C. "What medications are you currently taking?" D. "How would you characterize your mood lately?" E. "Do you have a consistent routine around getting ready for bed and going to bed?"

A. "Do you smoke?" C. "What medications are you currently taking?" D. "How would you characterize your mood lately?" E. "Do you have a consistent routine around getting ready for bed and going to bed?"

Which of the following is an example of a closed-ended question or statement? A. "Did you take those drugs?" B. "How did that medication make you feel?" C. "Tell me about things that relieve your pain?" D. "Describe the type of pain you have."

A. "Did you take those drugs?"

The client is newly diagnosed as having a terminal disease and asks, "I'm going to die soon, aren't I?" What would be appropriate replies of the nurse? [Select all that apply.] A. "Tell me how you feel." B. "No, you are not actively dying." C. "This is something I am not comfortable discussing." D. "What have you been told by your health care provider?" E. "You should ask your health care provider that question."

A. "Tell me how you feel." D. "What have you been told by your health care provider?"

Which of the following serum creatinine values would suggest to the nurse that a patient has compromised renal function? A. 1.8 mg/dL B. 18 mg/dL C. 1.018 D. 18 mEq/L

A. 1.8 mg/dL

Which of the following clients would be considered at risk for skin alterations? [Select all that apply.] A. A teenager with multiple body piercings B. A homosexual in a monogamous relationship C. A client receiving radiation therapy D. A client undergoing cardiac monitoring E. A client with diabetes

A. A teenager with multiple body piercings C. A client receiving radiation therapy E. A client with diabetes

The nurse cares for a successful chemical engineer, age 29 years, who is admitted with a respiratory infection. The client reports feeling more stress than ever since a job promotion six months ago and asks, "Why would something so positive and wonderful cause so much stress for me?" Which is an appropriate response by the nurse? [Select all that apply.] A. All major life events can cause stress for us. B. People vary greatly in their perception of what constitutes as a crisis or stressor. C. Your job promotion probably has nothing to do with the stress you feel. D. Positive life events do not cause stress or illness. E. Even positive life events can affect us in negative ways.

A. All major life events can cause stress for us. B. People vary greatly in their perception of what constitutes as a crisis or stressor. E. Even positive life events can affect us in negative ways.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse's assessment reveals a BP of 98/52 mmHg. The nurse should recognize that the client's kidneys will compensate by secreting what substance? A. Antidiuretic hormone (ADH) B. Aldosterone C. Renin D. Angiotensin

A. Antidiuretic hormone (ADH)

The nurse is assessing his client's self-concept. The client is status post-myocardial infarction and is due to be discharged tomorrow. Which of the following focuses will give the nurse the most information about the client's self-concept. [Choose all that apply.] A. Body image B. Gender identity C. Self-esteem D. Role performance E. Sexual orientation

A. Body image C. Self-esteem D. Role performance

A patient with hyperkalemia is at greatest risk to develop which of the following? A. Cardiac dysrhythmias B. Renal failure C. Tetany D. Laryngospasm

A. Cardiac dysrhuthmias

While performing the initial assessment of a client, the client tells the nurse that this is his first hospitalization and that he has no history of surgeries. The nurse should document which of the following? A. Client denies prior hospitalizations and surgery B. Client has not been hospitalized nor has he had any surgery C. Client has answered no to previous hospitalizations and surgery D. Negative for past hospitalizations

A. Client denies prior hospitalizations and surgery

A nurse provides client care within a philosophy of ethical decision making and professional expectations. What is the nurse using as a framework for practice? A. Code of Ethics B. Standards of Care C. Definition of Nursing D. Values Clarification

A. Code of Ethics

Which of the following clients is at an increased risk for oral problems? [Select all that apply.] A. Comatose client B. Confused client C. Depressed client D. Uninsured client E. Hypertensive client

A. Comatose client B. Confused client C. Depressed client D. Uninsured client

The nurse is caring for a female client today. As the nurse is giving the client her morning medications, she begins a conversation about her belief in a higher power. The nurse knows that this can be interpreted as which of the following? [Choose all that apply.] A. God B. Faith C. Religion D. Atheism E. Spirituality

A. God B. Faith C. Religion E. Spirituality

A child gains weight and becomes taller each year. What is this process called? A. Growth B. Development C. Progression D. Orderly change

A. Growth

Which of the following factors increase BMR? [Select all that apply.] A. Growth B. Infection C. Fever D. Emotional tension E. Aging

A. Growth B. Infection C. Fever D. Emotional tension

The nursing student is working to improve his time management. Which of the following would assist the nursing student in accomplishing his goal? [Select all that apply.] A. Identify priorities for the day. B. Evaluate time management at the end of the day. C. Establish a reasonable time line. D. Plan to arrive right at start of shift. E. Plan on his cohorts helping him.

A. Identify priorities for the day. B. Evaluate time management at the end of the day. C. Establish a reasonable time line.

The nurse is caring for a girl 13 years of age, who is admitted after taking some of her mother's sleeping pills. She is withdrawn and declines to eat or engage in conversation, except to say she doesn't like herself. The nurse is aware that potential causes of poor self-concept at this age can be related to which of the following? [Choose all that apply.] A. Inability to accept bodily changes B. Identity confusion C. Failure to accept role responsibility D. Failure to develop meaningful goals E. Inability to resolve child versus adult roles

A. Inability to accept bodily changes B. Identity confusion E. Inability to resolve child versus adult roles

The nurse is educating a Young Childcare class and one of the parents asks what kinds of actions on his part may increase safety for his 14-month-old daughter during the next 2 years. Which of the following responses would be appropriate? [Choose all that apply.] A. Keep medications locked away B. Keep plastic bags out of reach C. Use approved age car seats D. Teach to chew small food well E. Do not swing by arms or legs

A. Keep medications locked away B. Keep plastic bags out of reach C. Use approved age car seats E. Do not swing by arms or legs

The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs which of the following interventions to assist the client in adapting to this sensory deficit? [Select all that apply.] A. Make sure he wears his hearing aid. B. Speak in a lower tone of voice. C. Speak so he can observe your lip motions. D. Keep his environment clear of clutter. E. Orient to person, place, and time frequently.

A. Make sure he wears his hearing aid. B. Speak in a lower tone of voice. C. Speak so he can observe your lip motions.

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? [Select all that apply.] A. Monitor the client's respiratory rate. B. Note the amount of oxygen administered. C. Check the symmetry of the client's chest. D. Observe the breathing pattern and effort. E. Check the devices used to deliver oxygen.

A. Monitor the client's respiratory rate. C. Check the symmetry of the client's chest. D. Observe the breathing pattern and effort.

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A. Narrative notes B. Collaborative charting C. Charting by exception D. Paraphrasing documentation

A. Narrative notes

Which of the following statements accurately describes factors that may affect an individual's growth and development? [Select all that apply.] A. Physical characteristics such as height, bone size, eye color, and hair color are inherited from the family of origin. B. Fetal development can be altered by maternal age, inadequate maternal nutrition or substance abuse. C. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships, low self-esteem, and poor social skills. D. Infants who are malnourished in utero develop fewer brain cells than infants who have had adequate prenatal nutrition. E. Environmental factors such as poverty and violence do not have a direct effect on growth and development.

A. Physical characteristics such as height, bone size, eye color, and hair color are inherited from the family of origin. B. Fetal development can be altered by maternal age, inadequate maternal nutrition or substance abuse. C. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships, low self-esteem, and poor social skills. D. Infants who are malnourished in utero develop fewer brain cells than infants who have had adequate prenatal nutrition.

Which of the following are functions of the skin? [Select all that apply.] A. Protection B. Sensation C. Immunological D. Temperature regulation E. Vitamin C. production

A. Protection B. Sensation C. Immunological D. Temperature regulation

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of therapy? [Select all that apply.] A. Reduces muscle spasms B. Increases blood flow to tissues C. Constricts peripheral blood vessels D. Reduces the formation of edema and inflammation E. Increases the local release of pain-producing substances

A. Reduces muscle spasms C. Constricts peripheral blood vessels D. Reduces the formation of edema and inflammation

The clinic nurse sees the client today and asks about his chief complaint. The client describes to the nurse his inability to be intimate with his wife. Which of the following would be a priority for the nurse to assess? [Choose all that apply.] A. Sleep quality B. Medication prescribed C. Level of stress at work D. Social activity E. Specifics about sexual problem

A. Sleep quality B. Medication prescribed C. Level of stress at work E. Specifics about sexual problem

The Joint Commission supports the client's right to pain management, and published standards for assessment and management of pain in hospitals, ambulatory care settings, and home care settings (Joint Commission 2008b). Which of the following are recommended guidelines for pain management? [Select all that apply.] A. Teach all clients to use a pain rating scale. B. Determine a pain-rating goal with each client. C. Use pharmacologic pain relief measures first. D. Manipulate factors that affect the pain experience. E. Keep the primary care provider in charge of all pain relief measures.

A. Teach all clients to use a pain rating scale. B. Determine a pain-rating goal with each client. D. Manipulate factors that affect the pain experience.

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 do what? A. Terminate the plan of care. B. Modify the plan of care. C. Continue the plan of care. D. Re-evaluate the plan of care.

A. Terminate the plan of care.

While at lunch, a nurse heard other nurses at a nearby table talking about a patient they did not life. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating? A. basic respect for human dignity B. men do not gossip with women C. a low value on collegiality and friendship D. the importance of food in meeting a basic human need

A. basic respect for human dignity

Which age group in the population is expanding most rapidly, resulting in changes in the delivery of healthcare? A. older adults B. young adults C. newborns D. school-aged children

A. older adults

The family of a patient in a burn unit asks the nurse for information. The nurse sits with the family and discusses their concerns. What type of communication is this? A. small group B. interpersonal C. organization D. intrapersonal

A. small group

You are working on a burn unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

D. Hypovolemia

A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the unit? A. Place the client in a shared room with a client who is stable and oriented. B. Orient the client to the room and environment thoroughly upon admission. C. Provide the client with a bedpan to reduce the need to transfer to a commode or washroom. D. Administer pain medications sparingly in order to minimize cognitive or musculoskeletal side effects.

B. Orient the client to the room and environment thoroughly upon admission.

A patient tells the nurse that he does not want to answer any questions while his wife is present at the bedside. By respecting and supporting the patient's right, what is the nurse demonstrating? A. justice B. altruism C. advocacy D. confidentiality

D. confidentiality

Which of the following is considered an isotonic IV solution? A. 5% dextrose/0.45% NSS B. 0.9% NSS C. 0.45% NSS D. 3% NSS

B. 0.9% NSS

A nurse is conducting an intake assessment and wants to determine a client's ethnicity. Which of the following is the BEST way for the nurse to conduct this assessment? A. Observe the practices of the client over the shift. B. Ask whether the client identifies with a particular culture or ethnic group. C. Ask other nurses for their opinion of the client's ethnicity. D. Observe the client for specific speech patterns or clues to ethnicity.

B. Ask whether the client identifies with a particular culture or ethnic group.

A student nurse is assigned to care for a preschool chid who is scheduled for surgery. How can the student decrease the child's fears about the surgery? A. Explain that nothing is going to hurt and that it will soon be over. B. Be honest about the pain and use words the child can understand. C. Ask the child's parents to pretend that nothing is going to be done. D. Ignore the child's fears and focus on teaching the parents.

B. Be honest about the pain and use words the child can understand.

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A. Process, documentation, analysis, reporting B. Data, information, knowledge, wisdom C. Research, data, controls, variables D.Hypothesis, nursing, practice, evaluation

B. Data, information, knowledge, wisdom

A patient is diagnoses with pyelonephritis. Which nursing action is a priority for care now? A. Monitor hemoglobin levels B. Ensure sufficient hydration C. Insert a urinary catheter D. Stress the importance of the use of long-term antibiotics

B. Ensure sufficient hydration

A patient with hypoparathyroidism complains of numbness and tingling in the fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia

B. Hypocalcemia

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in the patient if excess fluid volume is present? A. Weight loss B. Increased Blood Pressure C. Flat neck veins D. Increased BUN

B. Increased blood pressure

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A.Identifying a problem that cannot be changed B. Presuming to know the factors contributing to the problem C. Neglecting to identify potential complications related to the problem D. Identifying a problem without corroborating evidence in the statement

B. Presuming to know the factors contributing to the problem

A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? [Select all that apply.] A. Vitamins B. Proteins C. Fats D. Minerals E. Carbohydrates

B. Proteins C. Fats E. Carbohydrates

A nurse is reading a physician's progress notes that the physician has documented insensible fluid loss of approximately 800 mL daily. The nurse understands that this type of fluid loss can occur through: A. Wound drainage B. The skin C. Urinary output D. The GI tract

B. The skin

The nurse is caring for a client who describes changes in his voiding patterns. The client states, "I feel the urge to empty my bladder several times in an hour and when the urge hits me I have to get to the restroom quickly. But when i empty the bladder, there doesn't seem to be much urine flow." What would the nurse expect this client's physical assessment to reveal? A. Hematuria B. Urinary retention C. Dehydration D. Kidney injury

B. Urinary retention

In which of the following cases should a progress note be written? [Select all that apply.] A. For any nurse-client interaction. B. When admitting a client. C. When receiving a client postoperatively. D. When assisting a client with ADLs. E. When a procedure is performed.

B. When admitting a client. C. When receiving a client postoperatively. E. When a procedure is performed.

Which of the following is considered a hypotonic IV solution? A. Lactated Ringers solution B. 5% dextrose/water C. 0.25% NSS D. 5% dextrose/NSS

C. 0.25% NSS

The nurse is caring for a female client 64 years of age who is admitted for knee replacement. As the nurse performs the shift assessment, the client comments, "I wouldn't mind getting old if I were not for the physical losses, like the wrinkles, all the drooping, and the wearing out of everything. People like to be around youthful, beautiful men and women; I feel so unattractive." Is the client correct about how society view older people? In general, which of the following does society emphasize and reward? [Choose all that apply.] A. Wisdom and sharing B. Youthfulness C. Mentoring the inexperienced D. Health and fitness E. Physical attractiveness

B. Youthfulness D. Health and fitness E. Physical attractiveness

Which of the following is an essential component in the definition of patient learning? A. decreases stress B. can be evaluated C. cannot be confirmed D. increases self-worth

B. can be evaluated

Amy Jones, a high school senior wants to become a nurse midwife. What nursing degree will she need to attain this goal? A. license practical nurse B. masters degree C. baccalaureate degree D. associate degree

B. masters degree

Which of the following statements accurately describes how risk factors may increase a person's chances for illness or injury? [Select all that apply.] A. Risk factors are unrelated to the person or event. B. All risk factors are modifiable. C. An increase in risk factors increases the possibility of illness. D. An increase in risk factors increases the possibility of illness. E. Middle-aged adults are at high risk for communicable diseases.

C. An increase in risk factors increases the possibility of illness. D. An increase in risk factors increases the possibility of illness.

A nurse is discharging a client from the hospital. When should discharge planning be initiated? A. At the time of discharge from an acute health care setting B. Before admission to an acute health care setting C. At the time of admission to an acute health care setting D. When the client is at home after acute care

C. At the time of admission to an acute health care setting

What care would the nurse recommend to the family of a client who is diabetic, regarding foot care? [Select all that apply.] A. Cut the toenails very short B. Cut the left and right nail corners C. Avoid cutting into calluses D. Cut the nails straight across E. Use plenty of lotion on the feet and toes

C. Avoid cutting into calluses D. Cut the nails straight across

The nurse is caring for a client suspected of having renal dysfunction. When reviewing laboratory results for this client, the nurse interprets the presence of which substances in the urine as the most suggestive of pathology? A. Potassium and sodium B. Bicarbonate and urea C. Glucose and protein D. Creatinine and chloride

C. Bicarbonate and urea

A nurse who provides care in a long-term care facility recognizes the need to promote health rather than solely treating illness. Which of the following measures should the nurse encourage among the older adult resident population of the facility? [Select all that apply.] A. Encourage frequent naps in order to ensure adequate sleep and rest. B. Encourage residents to consume diet and energy supplements. C. Conduct activities at a slower pace and allow residents time to respond. D. Encourage residents to engage in the present rather than perform reminiscence. E. Promote self-care and only assist residents when it is necessary.

C. Conduct activities at a slower pace and allow residents time to respond. E. Promote self-care and only assist residents when it is necessary.

While teaching a patient with chronic renal failure to perform daily peritoneal dialysis catheter care with instruction would be an important to emphasize? A. Be sure to empty the bladder before each treatment B. Change the dressing weekly C. Examine the site for signs of infection while cleaning the area D. Pull on the catheter and hold taught while cleaning the skin

C. Examine the site for signs of infection while cleaning the area

The client is admitted with a serum sodium level of 100 mEq/L. What is the priority nursing intervention? A. Encourage fluids orally B. Administer a 10% dextrose solution C. Initiate seizure precautions D. Notify the physician

C. Initiate seizure precautions

Which of the following statements accurately describes recommended guidelines for overcoming resistance for change? [Select all that apply.] A. Explain the proposed changes only to the managers of the people involved. B. Whenever possible, use technical language to describe the changes. C. List the advantages of the proposed change for members of the group. D. Avoid relating the change to the group's existing beliefs and values. E. If possible, introduce change gradually.

C. List the advantages of the proposed change for members of the group. E. If possible, introduce change gradually.

The mother of a toddler with asthma seeks support from the parents of other children with asthma. The nurse recognizes that seeking and utilizing support systems is an example of which human dimension? A. Physical dimension B. Environmental dimension C. Sociocultural dimension D. Intellectual and spiritual dimension

C. Sociocultural dimension

A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to the UAP? [Select all that apply.] A. Ensure that UAPs closely follow the nursing process when providing care. B. Audit the client documentation that UAPs record after they perform interventions. C. Take frequent mini-reports from UAPs to ensure changes in client status are identified. D. Know what clinical cues the UAP should be alert for and why. E. Make frequent walking rounds to assess clients.

C. Take frequent mini-reports from UAPs to ensure changes in client status are identified. D. Know what clinical cues the UAP should be alert for and why. E. Make frequent walking rounds to assess clients.

A client scheduled for complex heart surgery has been reading the Bible for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client? A. These behaviors are expected before major surgery. B. Family members live far away and the client is lonely. C. These behaviors are signs of spiritual distress. D. The client is naturally emotional and reactive.

C. These behaviors are signs of spiritual distress.

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of: A. case management B. telemedicine C. nursing informatics D. information technology

C. nursing informatics

The importance of standardized language when documenting in healthcare is meant to A. challenge nursing research B. increase the risk of fragmentation in reporting C. provide standardized terminology to use in EHRs D. makes the profession of nursing invisible

C. provide standardized terminology to use in EHRs

A competent adult patient is scheduled for surgery. Who signs the information consent form to allow for the surgery? A. the spouse B. the physician C. the patient D. the nurse

C. the patient

What is the primary purpose of standards of nursing practice? A. to establish nursing as a profession and a discipline B. to provide a method by which nurses perform skills rapidly C. to help ensure knowledgable, safe, comprehensive nursing care D. to enable nurses to have a voice in healthcare policy

C. to help ensure knowledgable, safe, comprehensive nursing care

The nurse is educating the mother of an infant age 4 months on safety concepts in child rearing. Which of the following statements by the mother suggests that she may require some repetition and reinforcement of the information? A. "I must keep small objects out of the baby's reach." B. "The baby will sleep in her crib, not with me and my husband." C. "I must keep appointments for the baby's immunizations." D. "The baby can sleep on her stomach during naps."

D. "The baby can sleep on her stomach during naps."

A patient with history of chronic renal failure receives hemodialysis treatments tree times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? A. Keep the AV fistula site dry B. Keep the AV fistula wrapped in gauze C. Take the client's blood pressure in the left arm D. Assess the AV fistula for a bruit and a thrill

D. Assess the AV fistula for a bruit and thrill

A nurse is caring for an adolescent who is in the hospital for a long-term illness. Which of the following interventions would promote the development of the hospitalized adolescent? A. Provide the teen structure in daily activities. B. Encourage the family to have fun game night activities once a week. C. Arrange for a tutor to cover missed schoolwork. D. Connect the teen to their peer group as much as possible.

D. Connect the teen to their peer group as much as possible.

A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A. Nothing, the nurse's honesty will not be questioned. B. The nurse can add the documentation after the client goes home. C. The physician will verify that the nurse carried out the order. D. In the eyes of the law, if it is not documented, it was not done.

D. In the eyes of the law, if it is not documented, it was not done.

A patient is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include: A. Green tinged urine B. Moderate to severe hypotension C. Polyuria D. Periorbital edema

D. Periorbital

Which of the following is an important role for the nurse when incorporating principles and theories of growth and development? A. initiate interventions to meet specific outcomes of care B. provide physical care to meet needs of young children C. initiate activities that involve passive interactions with others D. provide developmentally challenging environments and experiences

D. provide developmentally challenging environments and experiences

What nursing activity would meet the broad nursing aim of facilitating coping with disability and death? A. conducting a blood pressure screening program B. performing a physical assessment on a patient C. administering intravenous fluids and oral medication D. referring patients and families to community support groups

D. referring patients and families to community support groups

Surface temperature measurement is expected to be higher than core temperature. [True or False?]

False (higher --> lower)

The center of control of temperature in one's body is the pituitary gland. [True or False?]

False (pituitary gland --> hypothalamus)

The __________________ pulse is considered to be the most __________________ reading of heart rate, pulse, and should be auscultated for __________________.

apical reliable 1 full minute

Transfer of heat from a warm to a cool surface by direct contact is called __________________.

conduction

Tow factors that can impact pulse rate are __________________ and __________________.

developmental level gender exercise food intake stress fever disease blood loss position change medication

A nurse is analyzing data of a client who has been admitted for heart failure. The nurse has determined that the clue clusters meet the defining characteristics of a specific diagnosis. Which of the following would the nurse do next? A. Explain the client's problems to the client and the family B. Verify the findings with the client and other health care professionals C. Validate the nursing diagnosis with the physician D. Work with the client to begin planning interventions

D. Work with the client to begin planning interventions

Which of the following is a criteria that defines nursing as a profession? A. an undefined body of knowledge B. a dependence on the medical profession C. an ability to diagnose medical problems D. a profession that places patients in the center of care

D. a profession that places patients in the center of care

Core temperature below normal (less than 95ºF or 35ºC) is known as __________________.

hypothermia

Which of he following are functions of the skin? [Select all that apply.] A. Sensation B. Protection C. Temperature regulation D. Immunological E. Vitamin C production

A. Sensation B. Protection C. Temperature regulation D. Immunological

In general, how do most people view change? A. By how it affects the cohesiveness of the group B. By how much it will cost in time and resources C. By how it will affect others on the staff D. By how they are affected personally

D. By how they are affected personally

An elderly woman has total care of her husband, who suffers from debilitative rheumatoid arthritis. The couple voices concern over the pain and stress associated with the condition. What type of care might the nurse suggest to help the couple? A. Primary care B. Respite care C. Bereavement care D. Palliative care

D. Palliative care

The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including a frequent and productive cough. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment? A. Eye goggles B. Face mask C. Cover gown D. Face shield

B. Face mask

The client was diagnosed with diabetes three years ago, but has failed to integrate regular blood glucose monitoring or dietary modifications into his lifestyle. He has been admitted to the hospital for treatment of acute renal failure secondary to diabetic neuropathy, an event that has prompted the client to reassess his values. Which of the following actions most clearly demonstrates that this client is engaging in the step of prizing his valuing process? A. The client is now able to explain how his choices have contributed to his renal failure. B. The client states that he will now begin to check his blood glucose before each meal and at bedtime. C. The client expresses remorse at his his failure to make lifestyle changes has adversely affected his health. D. The client expresses pride that he now has the knowledge and skills to take control of his diabetes management.

D. The client expresses pride that he now has the knowledge and skills to take control of his diabetes management.

A healthy client is on a regular diet 24 hours postpartum. The client's mother asks the nurses if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle? A. Foods from home are generally discouraged on the postpartum unit. B. This is permissible as long as the foods are nutritious and high in iron. C. The client's health care provider (HCP) needs to give permission for the foods. D. The mother can bring the daughter any foods that she desires.

D. The mother can bring the daughter any foods that she desires.

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

D. To design a plan of care for and with the client

According to Erikson, normal adolescent behavior includes trying on new roles and possibly even rebelling. What is the purpose of this behavior in adolescents? A. To gain autonomy B. To avoid inferiority C. To establish a sense of security D. To establish a sense of identity

D. To establish a sense of identity

The time of infection until manifestation of symptoms, a likely time to infect others is defined as the __________________ stage.

incubation

The emergency department nurse is caring for an infant age 2 months who was brought in by a hired caregiver. The infant is underweight and looks uncared for. The caregiver reports that the mother of the infant is unreliable and may be using drugs; the infant is often unclean and hungry when dropped off at the caregiver's home. The infant has diaper rash and a weak cry. If this situation is not remedied, what will this infant have difficulty achieving, according to Erikson's developmental theory? A. Autonomy B. Trust C. Identity D. Initiative

B. Trust

A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? A. administer the medication based on the order B. question the order for the medication C. refuse to administer the medication D. document concerns about the order

B. question the order for the medication

Which of the following are examples of breaches of client confidentially? [Select all that apply.] A. A nurse discusses a client with a coworker in the elevator. B. A nurse shares her computer password with a relative of a client. C. A nurse checks the medical record of a client to see who should be called in an emergency. D. A nurse updates the employer of a client regarding the client's return to work. E. A nurse uses a computer to document a client's response to pain medication.

A. A nurse discusses a client with a coworker in the elevator. B. A nurse shares her computer password with a relative of a client. D. A nurse updates the employer of a client regarding the client's return to work.

Which of the following are examples of incidental disclosures of client health information that are permitted? [Select all that apply.] A. A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B. Two nurses are overheard talking about a client through the door of an empty client room. C. A nurse places a client chart in a holder on the examining room door with the name facing out. D. A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E. A nurse calls out the name of a client who is seated in the waiting room.

A. A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B. Two nurses are overheard talking about a client through the door of an empty client room. E. A nurse calls out the name of a client who is seated in the waiting room.

Which of the following are conditions that must be met for a person to receive the necessary data to experience the world? [Select all that apply.] A. A stimulus must be present. B. A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. C. The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. D. The stimulus must be recognized by the cardiovascular system and sent to the brain. E. The person must physically and mentally recognize the stimulus and accept or reject it in the brain. F. A particular area in the brain must receive and translate the impulse into a sensation.

A. A stimulus must be present. B. A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. C. The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. F. A particular area in the brain must receive and translate the impulse into a sensation.

A 12-year-old African-American client has experienced significant blood loss and may require a blood transfusion. The child's mother, father, and sisters are currently present at the child's bedside in the emergency department. How should the nurse direct questions and teaching about the client's condition and treatment? A. Assess who is the dominant member of the family and then address that person. B. Address the mother, as African-American families are commonly matriarchal. C. Ask the child's father what should be done, but make eye contact with everyone in the room. D. Direct questions to the family collectively to avoid presuming who is dominant.

A. Assess who is the dominant member of the family and then address that person.

Which activity does the nurse engage in during evaluation? [Select all that apply.] A. Collect data to determine whether desired outcomes are met. B. Assess the effectiveness of planned strategies. C. Adjust the time frame to achieve the desired outcomes. D. Involve the client's family in formulating desired outcomes. E. Initiate activities to achieve the desired outcomes.

A. Collect data to determine whether desired outcomes are met. B. Assess the effectiveness of planned strategies. C. Adjust the time frame to achieve the desired outcomes.

A female client is told that she needs a pelvic examination and she replies "Absolutely not!". Which response by the nurse would be appropriate? A. Explain the importance of the exam but respect her wishes and omit the test B. Tell the client that this is the only way to check for cancer C. Ask the client if she would like another practitioner to perform the exam D. Proceed with the exam and document the client's protests in the health record

A. Explain the importance of the pelvic exam but respect her wishes and omit the test

Which of the following is a correctly written goal? [Select all that apply.] A. The client will identify five low-sodium foods by October 9. B. The client will know the signs and symptoms of an infection. C. The client will rate pain as a 3 or lesson a 10-point scale by 5pm today. D. The client will understand the side effects of digoxin (Lanoxin). E. The client will eat at least 75% of all meals by May 5.

A. The client will identify five low-sodium foods by October 9. C. The client will rate pain as a 3 or lesson a 10-point scale by 5pm today. E. The client will eat at least 75% of all meals by May 5.

An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A. The client's airway should be assessed. B. The client's past medical history is assessed. C. The nurse should review the client's medications. D. The nurse should determine the reason for admission.

A. The client's airway should be assessed.

Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client? A. The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it. B. The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client. C. The health care facility directs the nursing diagnosis in order to receive payment for services performed. D. The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client.

A. The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.

While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude? A. These are normal physiologic changes of aging. B. The observations are not typically found in older males. C. These are abnormal and must be reported. D. Extra education will be necessary to prevent complications.

A. These are normal physiologic changes of aging.

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? [Select all that apply.] A. U (unit) B. QD (daily) C. NPO (nothing per os) D. mL (milliliters) E. gt (greater than)

A. U (unit) B. QD (daily) E. gt (greater than)

The nurse is performing an assessment on a client with a history of a dysfunctional family. What findings should the nurse anticipate? [Select all that apply.] A. Unhealthy personal boundaries B. Supportive parents C. Abuse and neglect D. Direction and attention E. Structured limit setting

A. Unhealthy personal boundaries C. Abuse and neglect

While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer the questions than with younger patients. What should the nurse do? A. realize that the patient has some dementia B. slow the pace and allow extra time for answers C. ask a family member to answer the questions D. stop asking questions so as not to confuse the patient

B. slow the pace and allow extra time for answers

A nurse tells a patient, "Why won't you get out of bed? Are you always this lazy? This is an example of which fo the following barriers to communication? A. using leading questions B. using probing questions C. using judgmental language D. using comments that give advice

C. using judgmental language

Which of the following statements accurately describes a recommended guideline for implementation? [Select all that apply.] A.When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B. Before implementing any nursing action, reassess the client to determine whether the action is still needed. C. Assume that the nursing intervention selected is the best of all possible alternatives. D. Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E. Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

B. Before implementing any nursing action, reassess the client to determine whether the action is still needed. D. Consult colleagues and the nursing and related literature to see if other approaches might be more successful.

A nurse caring for a client admitted to the intensive care unit with a severe headache assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A. Initial assessment B. Focused assessment C. Time-lapsed assessment D. Emergency assessment

B. Focused assessment

A nurse is considering the delegation of administering medications to an unskilled assistant . What is the first question the nurse must ask herself before doing so? A. Has the assistant been trained to perform this task? B. Is the delegated task permitted by law? C. Have I evaluated the client's response to this task? D. Is appropriate supervision available?

B. Is the delegated task permitted by law?

Which of the following statements is true for nursing care of older adults? A. Most older adults are unable to care for themselves independently. B. Most older adults are functional, benefiting from health-oriented interventions. C. Fewer older adults will require nursing care during the 21st century. D. Interventions for older adults are no different from those for young adults.

B. Most older adults are functional, benefiting from health-oriented interventions.

A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? A. Teaching the client about her right to autonomy B. Respecting the client's desire to have the uncle make choices on her behalf C. Revisiting the decision when the uncle is not present at the bedsire D. Holding a family meeting and encouraging the client to speak on her own behalf

B. Respecting the client's desire to have the uncle make choices on her behalf

A nurse is responding to sexual harassment from a client at work. Which of the following is a recommended guideline for dealing with this behavior? A. Do not confront the person harassing you in person. B. Set and enforce limits to the behavior and maintain boundaries. C. If confronted by management, deny any feelings about being harassed. D. Document the incident but do not report it to the supervisor unless harassment continues.

B. Set and enforce limits to the behavior and maintain boundaries.

A nurse is sitting near a patient while conducting a health history. The patient keeps edging away from the nurse. What might this mean in terms of personal space? A. The nurse is too far away from the patient B. The nurse is in the patient's personal space C. The patient does not like the nurse D. The patient has concerns about the questions

B. The nurse is in the patient's personal space

Which of the following statements illustrates the effect of the sociocultural dimension on health and illness? A. "My mother has sickle cell anemia, and so do I." B. "I used biofeedback to lower my blood pressure." C. "Why shouldn't I drink and drive? Everyone else does." D. "I know I have heart problems, so I have changed my diet."

C. "Why shouldn't I drink and drive? Everyone else does."

According to Erikson's theory of development, chronic illness will have the greatest impact on which client? A. 1-year-old B. 3-year-old C. 14-year-old D. 41-year-old

C. 14-year old

Which of the following models of health promotion and illness prevention was developed to illustrate how people interact with their environment as they pursue health? A. The health belief model B. The health-illness continuum C. The health promotion model D. The agent-host-environment model

C. The health promotion model

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A. The nurse should update the database. B. The nurse should modify the data collection tool. C. The nurse should practice interviewing strategies. D. The nurse should determine the specific purpose of data collection.

C. The nurse should practice interviewing strategies.

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? A. The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. B. The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time. C. The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention. D. The nurses have given multiple opportunities for potential participants to ask questions, and have been following the informed consent process systematically.

C. The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention.

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. making a commitment to others B. trying on new and different roles C. reminiscing about life events D. becoming involved within the community

C. reminiscing about life events

An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000 (high), and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A. Goal partially met; client identified fever and presence of wound discharge. B. Client understands the signs and symptoms of infection. C. Goal partially met; client able to perform activities of daily living. D. Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

D. Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls? [Select all that apply.] A. Keep bed in the high position. B. Keep all side rails up at all times. C. Apply restraints to all confused clients. D. Lock wheels on beds and wheelchairs. E. Clear pathway from patient's bed to bathroom.

D. Lock wheels on beds and wheelchairs. E. Clear pathway from patient's beed to bathroom.

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

D. No, this is a description of normal snoring

Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A. Phrase the nursing diagnosis as a client need. B. Incorporate subjective and judgmental terminology. C. Place the etiology prior to the client problem and linked by the phrase "related to". D. Place defining characteristics after the etiology and link them by the phrase "as evidenced by".

D. Place defining characteristics after the etiology and link them by the phrase "as evidenced by".

A patient gets out of bed following hip surgery and falls and re-injures her hip. The nurse caring for her knows that it is her duty to make sure an incident report is filed. Which of the following statements accurate describe the correct procedure for filing an incident report? A. The physician in charge should fill out the report B. The names of the staff involved need not to be included C. The report will be used for disciplinary action against the staff D. The report should contain all the facts related to the incident

D. the report should contain all the facts related to the incident

"A state of cleanliness that decreases the potential for the spread of infections" is called __________________ asepsis.

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