Prep U FINAL

Which statement made by the nurse would indicate that teaching was effective regarding the absorption of topical medications for the older adult?

"A diminished subcutaneous fat will lead to the rapid absorption of topical medication."

The nurse just attended a seminar on cultural diversity. Which statement by the nurse would require further education?

"Ethnicity and race are the same thing and are affected by cultural practice."

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?

"Nasal strips may reduce or eliminate snoring."

A client with a nonhealing pressure ulcer has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response?

"Wounds heal because HBOT helps to regenerate new tissue quickly."

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+ The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2,500 mL

The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?

25

A nurse needs to administer a continuous medication drip to a client. The nurse knows that, for a continuous infusion, she will likely need to add medication to which volume of IV solution?

500 to 1,000 mL

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date.

Which instruction should the nurse give to a client to ensure the nasal medication is deposited within the nose rather than into the throat?

Aim the tip of the container toward the nasal passage

A client prescribed pain medication around the clock experiences pain one hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

Assess for medication order for breakthrough pain.

A nurse receives orders from the physician to mix a client's insulin in a syringe with two other medications. What is the recommended guideline in this situation?

Call the pharmacist to determine compatibility of the drugs.

Which peripheral pulse site is generally used in emergency situations?

Carotid

A client is receiving a secondary infusion of a new antibiotic through a peripherally inserted central line (PICC). After 5 minutes of administration, the client reports itching and appears flushed. What is the most appropriate nursing intervention?

Clamp PICC line

A client with a central venous catheter develops signs of air embolism. Which action would the nurse do first?

Clamp the existing catheter

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

Coping strategies

A client is receiving opioid analgesia for pain control. The nurse is assessing the client for possible respiratory depression. Which method would be most reliable for the nurse to use to identify impending respiratory depression?

End tidal CO2

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

Which PPE should be removed first?

Gloves

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received.

Which of the following describes lower-brain death?

It results in the inability to maintain circulation and respiration and is ventilator dependent

A nurse is part of an orientation team for a group of newly hired nurses. The nurse is to prepare a presentation for the group about different cultural groups common to the facility. As part of the presentation, the nurse is planning to describe how culture is communicated to provide a foundation for culturally competent care. Which methods of communication would the nurse include? Select all that apply.

Language Behavior Symbols

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics

While auscultating a client's chest, a nurse hears coarse crackles that are soft, high-pitched and discontinuous. The nurse interprets this finding as indicating which of the following?

Presence of sputum in the airways

Which teaching will the nurse provide to a client with the NANDA-I nursing diagnosis of "Ineffective Protection related to cancer and chemotherapy treatment"?

Refrain from using aspirin while undergoing chemo treatment.

The nurse is preparing the body of a client who was killed in a car accident for the family to view. Which step would be contraindicated?

Removal of all IVs and other medical tubing.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate.

The nurse is writing a care plan for the client experiencing spiritual distress. What is the priority outcome for this care plan?

The client states his belief in a higher being.

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

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

After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply?

Use silence and allow the husband to express his emotions.

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

WNL 5,000-10,000

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

A client has recently lost his father. The client spent about 6 months deeply mourning his loss and is just now able to function at his pre-loss level. He was helped in this process by his strong social support. This client is most likely a(an):

adult

During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that:

breathing becomes increasingly difficult as the diaphragm is displaced.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

What does the nurse expect to be included in the directions for reconstitution on a drug label? (Select all that apply.)

directions for storing the drug amount of diluent to be added dosage per volume after reconstitution

A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating?

faith

The client states "I have lifted my cancer to God and am accepting of God's plan for me." This is an example of an adaptive expression of spiritual needs labeled:

faith

The process of filtration begins:

glomerulus

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

guarding of the chest area

A woman age 20 years has announced her intention to implement a zero-fat diet in order to lose weight and maximize her health. What is a potential consequence of completely eliminating fat sources from the woman's diet?

impaired vitamin absorption

Today you are caring for Mr. Glanden, who recently underwent a lung resection. As you go about your physical assessment, he asks to have the elders from his church perform a "laying on of hands". You interpret this as a healing process associated which of the following religions?

mormon

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

The wife of a client asks the nurse if she could bring in a cream from home to apply to her husband's skin. She says, "Whenever anyone gets sick we always use this cream." The nurse interprets this as:

ritual

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should:

take measures to ensure privacy during the counselor's visit.

A client with headaches has been told by the healthcare provider to increase intake of dietary magnesium. Which food will the nurse teach the client to consume?

whole grains