RN quiz
A nurse is completing dietary teaching with a client who has heart failure and has a prescription for a 2 g sodium diet. Which of the following statements made by the client indicates an understanding of the teaching? a. "I can have nonfat yogurt as a dessert" b. "I can eat processed foods as long as it has less than 500 mg of sodium per serving" c. "I can use baking soda when I bake" "I should season my foods with salt sparingly"
ANSWER: a. "I can have nonfat yogurt as a dessert" rationale: a. The nurse should identify that yogurt is a recommended dessert for a client on a 2 g sodium diet who has heart failure because it is low in sodium and fat. b. The nurse should instruct the client to consume processed foods sparingly and to ensure each serving has less than 300 mg of sodium. c. The nurse should instruct the client to bake goods without the use of baking soda, which is high in sodium. d. The nurse should instruct to client to avoid seasoning foods with salt. The client can use herbs, spices, or lemon juice to add flavor to foods.
A nurse is delegating tasks for four clients. Which of the following tasks should the nurse delegate to the assistive personnel (AP)? a. prepare the room for a client who requires seizure precautions b. check a client's deep tendon reflexes (DTR) c. develop a plan of care for a client who is at risk for falling d. obtain a wound culture on a client who has a small pressure injury
ANSWER: a. prepare the room for a client who requires seizure precautions rationale: a. An AP can set up a room with the equipment a client requires for seizure precautions because the necessary equipment is the same for each client. b. A nurse cannot delegate checking a client's deep tendon reflexes to an AP because this task requires the assessment skills of a nurse. c. A nurse cannot delegate developing a plan of care to an AP because this task requires use of the nursing process. d. A nurse cannot delegate obtaining a wound culture to an AP because this task requires nursing knowledge and judgment.
A charge nurse is teaching a newly hired nurse about the facility's computerized documentation system. Which of the following actions should the nurse take? a. direct the newly hired nurse to wait until the end of the shift to document client care b. instruct the newly hired nurse to use direct quotes when recording client statements c. perform documentation for the newly hired nurse until the orientation period is complete d. Print records from previously discharged clients as examples for the newly hired nurse to review
ANSWER: b. instruct the newly hired nurse to use direct quotes when recording client statements rationale: a. The charge nurse should instruct the newly hired nurse to document client care throughout the shift. Documenting care as it is performed helps to reduce the risk of errors or omissions. b. The newly hired nurse should include both subjective data, what the client says, and objective data, what the nurse observes, when entering computer documentation. It is important to directly quote what the client says rather than summarizing to provide factual information. c. The charge nurse should not perform documentation for another staff member. The exception is when a staff member has left the facility and forgot to record pertinent information. d. The charge nurse should only show the newly hired nurse records of clients that they are caring for to protect the confidentiality of other clients.
A nurse is evaluating the developmental motor skills of a 4-month-old infant. Which of the following findings should the nurse expect? a. uses a spoon to feed herself b. sits up with support c. uses a pincher grasp d. creeps on hands and knees
ANSWER: b. sits up with support rationale: a. The nurse should expect an infant to use utensils to feed herself by 12 months of age. b. The nurse should expect a 4-month-old infant to be able to sit up with support. By this age, the infant should have no head lag when sitting. c. The nurse should expect an infant to use the pincher grasp at 9 months of age. d. The nurse should expect an infant to creep on their hands and knees at 9 months of age.
A nurse is planning care for four clients. Which of the following clients should the nurse see first? a. a client who has diabetes mellitus and a fasting blood glucose of 68 mg/dL b. a client who has moderate serosanguineous drainage on a surgical dressing c. a client who has pneumonia and expiratory wheezing d. a client who has a PCA pump and reports pain as a 7 on a scale of 0-10
ANSWER: c. rationale: a. The nurse should assess a client who has a blood glucose level of 68 mg/dL and provide them with a snack; however, the nurse should assess another client first. b. The nurse should assess this client to monitor the drainage on the surgical dressing; however, the nurse should assess another client first. c. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's airway and breathing, which could be impaired as a as a result of the pneumonia. When using the airway, breathing, circulation approach to client care, the nurse should plan to see the client who has pneumonia and expiratory wheezing first. The nurse should auscultate the client's lungs and measure their oxygen saturation. d. The nurse should assess a client who reports pain as a 7 on a scale of 0 to 10 to determine if the client can receive additional pain medication; however, the nurse should assess another client first.
A nurse is admitting a client to an acute care facility. Which of the following actions by the nurse promotes client self-determination? a. reviewing the policy on safeguarding personal valuables with the client b. informing the client's family about the regulations for visitation hours c. providing the client with information about end-of-life decision-making d. comparing the client's home medications to the admission prescriptions
ANSWER: c. providing the client with information about end-of-life decision-making rationale: a. The nurse should assist the client to protect their valuables to prevent theft. b. The nurse should inform the client's family about visitation regulations to promote rest for the client. c. By promoting the client's autonomy, the nurse ensures the client's ability to self-determine care. Under the Patient Self-Determination Act, facilities must ensure a client is aware of their rights to make choices about their care, including completing advance directives to predetermine end-of-life treatment options. d. The nurse should compare the client's home medications to the admission prescription to promote client safety.
A nurse is caring for a client who is recovering from a stroke and tells the nurse he is concerned about paying his medical bills. The nurse should refer the client to which of the following members of the interprofessional health care team? a. physical therapist b. occupational therapist c. social worker d. speech pathologist
ANSWER: c. social worker rationale: a. A physical therapist can assist the client with musculoskeletal problems. b. An occupational therapist can assist the client with skills to perform activities of daily living. c. The nurse should refer the client to a social worker to assist the client with finding available financial resources. d. A speech pathologist can assist the client who is experiencing dysphagia.
A nurse is completing an informed consent document for a 16-year-old adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take? a. locate the adolescent's partner to sign the form prior to the appendectomy b. document consent is implied due to the urgency of the procedure c. tell the client that a general consent to treatment covers the surgical procedure d. ask the client if they understand the provider's plan for the appendectomy
ANSWER: d. ask the client if they understand the provider's plan for the appendectomy rationale: a. The nurse should identify that the client's partner can sign a consent form only if the client is unable or incompetent to do so. b. The nurse should identify that implied consent is used for noninvasive procedures, such as obtaining vital signs, in which the client implies consent by allowing the action to take place. c. The nurse should recognize that a general consent to treatment does not address invasive and high-risk procedures. d. To ensure informed consent, the nurse should ask the client if they understand the planned procedure. In most states, a married adolescent is considered emancipated, and has the legal authority to provide their own consent.
A nurse in a community health center is teaching a group of clients about the use of aromatherapy. The nurse should include in the teaching that which of the following essential oils is used to alleviate swollen joints? a. lavender b. jasmine c. sage d. chamomile
ANSWER: d. chamomile rationale: a. Lavender is an essential oil that can be used for a calming effect or as a sedative to alleviate insomnia. b. Jasmine is an essential oil that can be used to stimulate mood or alleviate menstrual cramps and lower back pain. c. Sage is an essential oil that can be used to minimize gastrointestinal distress, to alleviate discomfort in the mouth and throat, and as a supplement to help treat depression. d. Chamomile is an essential oil that has anti-inflammatory properties that can be used to alleviate swollen joints and muscle aches.
A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following findings should the nurse report to the provider? a. gastric residual of 50 mL b. weight gain of 0.23 kg (0.5 lb) in 24 hr c. blood glucose of 105 mg/dL d. gastric aspirate pH of 7
ANSWER: d. gastric aspirate pH of 7 rationale: a. The nurse should report a gastric residual of greater than 100 mL for a client who is receiving continuous enteral feedings. A high gastric residual can indicate delayed gastric emptying and increases the client's risk for aspiration. b. The nurse should identify that a weight gain of more than 0.91 kg (2 lb) in 24 hr is a manifestation of fluid volume excess and places the client at risk for heart failure. c. The nurse should identify that a blood glucose of 105 mg/dL is within the expected reference range of 74 to 106 mg/dL. d. The nurse should identify that a gastric pH of 7 is an indication the nasogastric tube is not in the stomach. Gastric pH is usually between 1 and 4 but can be up to 6, if the client receives a medication that alters gastric pH. The client is at risk for aspiration and the nurse should report this finding to the provider.
A nurse is teaching a client about health promotion and secondary prevention strategies. Which of the following recommendations should the nurse include? a, influenza immunization b. rehabilitation therapy c. genetic screening d. hypertension screening
ANSWER: d. hypertension screening rationale: a. Immunizations are classified as primary prevention and are used to prevent help disease. Primary prevention focuses on decreasing the client's risk or exposure. b. Rehabilitation therapy is classified as tertiary prevention. Tertiary prevention focuses on the rehabilitation and restoration of the client's optimal level of functioning. c. A genetic screening is classified as primary prevention and is used to help prevent illness. Primary prevention focuses on decreasing the client's risk or exposure. d. A hypertension screening is an example of secondary prevention and focuses on early detection of a disease and interventions to provide prompt treatment of disease.
