sample questions

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) A. Increased risk of thrombus formation B. Increased cardiac workload C. Weak peripheral pulses D. Irregular heartbeat E. Orthostatic hypotension

A

The nurse is teaching the client and his wife about ways to promote rest and sleep. The nurse demonstrates techniques for administering a back massage on Mr. Olham. Which statement by the nurse is accurate? a. Effieurage the entire back using slow movement and light pressure b. Petrissage the small muscles of the lower back using slow movement and light pressure c. Client grimacing confirms effective kneading pressure is being used d. Warmed oil should be used after massage to sustain relaxation

A

The nurse's assessment findings include right-sided weakness, slurred speech, and dysphagia. The nurse identifies that Mrs. Rusk is at high risk for several problems. In developing the nursing plan of care, which problem has the highest priority? a) Aspiration b) Skin breakdown c) Altered nutrition d) Self-care deficit

A

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed B. Place the patient in a belt restraint—last resort & afraid for patient safety C. Provide one-on-one observation of the patient—expensive intervention D. Apply wrist restraints

A

What other questions should the nurse ask Janelle? a. "How often do you get out of bed and walk?" b. "Are you using your incentive spirometer regularly?" c. "When was your abdominal dressing last changed?" d. "Are you wearing your compression devices while in bed?"

A

The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 NREM from which of the following assessments? A. Irregular respirations B. Fluctuating blood pressure C. The patient is difficult to awaken. D. Eyes rapidly move—true in REM

C

The nurse plans to measure James' oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, James asks if it will hurt. Which response is the best for the nurse to provide? a. "Yes, but the pain will only last a very short time." b. "No, you will not even know the clips is on your finger." c. "The clip feels like squeezing your finger with your other hand." d. "You seem to be worried about experiencing pain."

C

Which serum lab value reflects Mrs. Rusk's altered nutrition? a) Sodium of 144mEq/L b) Calcium of 9.5mg/dL c) Potassium of 3.8mEq/L d) Protein of 5.0g/dL

D

Your patient has the nursing diagnosis: Acute pain related to surgical incision and muscle spasms secondary to repair of fractured hip. Which of the following is the best projected outcome statement? By discharge the patient will A. Demonstrate ability to ambulate with walker. B. Deny any complaint of pain. C. Report that he is sleeping better D. Rate pain as a 1-2 on a 0-10 scale

D

Which is the best explanation by the nurse for instructing Mr. Olham about the use of OSA? a. There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep. b. There is a dysfunction of mechanisms that regulate he sleep and wake states causing excessive sleepiness during a day. c. The airway remains open, but the brain falls to send messages to the diaphragm and chest muscles to initiate respirations. d. It is a syndrome characterized by chronic difficulty falling asleep with frequent awakenings at night.

A

Which is the best goal for the nurse to include in the plan of care related to the problem statement of "acute pain r/t strain on muscles with movement?" a. Client reports pain of less than 1 on a 0 to 10 scale b. Client will verbalize pain control methods c. Client will learn alternative methods for pain control d. Client will learn to live with long-term pain

A

Which of the following parents need additional instruction regarding safety? A. Parent A states "Now that my child is 2 years old I can let her sit in the front seat of the car with me." B. Parent B states "I make sure Tommy wears a helmet when he rides his bicycle." C. Parent C states " I have spoken to my teenager about safe sex practices." D. Parent D states "My 8 year old is taking swimming lessons at the YMCA."

A

Mr. Mathis is concerned that he may become constipated due to his lack of activity and poor diet. What action should the nurse implement in response to Mr. Mathis' concern? a. Plan to obtain a prescription for a hypertonic solution enema. b. Offer to obtain a bedside commode for Mr. Mathis c. Encourage the use of a bedpan after each meal d. Teach Mr. Mathis the importance of ambulation

B

Mr. Olham refuses to wear the CPAP mask while hospitalized. The night before his surgical procedure, the pulse oximeter alarms. The nurse enters Mr. Olham's room and observes that Mr. Olham is sleeping and that his oxygen saturation has decreased to 84%. Which priority action should the nurse implement? a. Quietly place an oxygen mask on the client without waking him b. Gently shake the client to awaken him c. Document the observation as an expected finding d. Request that the HCP to reevaluate the client's status

B

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect to find which of the following A. Increased blood pressure B. Weak, rapid pulse C. Moist mucous membranes D. Jugular vein distention

B

The nurse also observes that Donna's feet and ankles are swollen. When the nurse presses a finger over the client's ankle (bony prominence), an 8mm indention appears. How will the nurse document this finding? a) Gross edema in the lower extremities b) 4+ pitting edema present around ankles and feet c) Stage 1 pressure ulcer forming due to ankle edema d) Blanching and induration present bilaterally

B

The nurse is performing an assessment of an immobilized client. Which of the following causes him to take action? A. Heart rate 88 B. Reddened area on sacrum C. Nonproductive cough D. Voiding clear yellow urine

B

The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake? A. The patient was waiting to talk with the nurse. B. The patient misses his family and is lonely. C. The patient's sleep-wake cycle preference is late evening. D. The patient has been kept up with the noise on the unit.

C

The nurse recognizes that Mrs. Rusk's right-sided weakness is also a factor contributing to her risk for altered nutrition. With which member of the interprofessional team should the nurse consult regarding this problem? a) Bariatrics specialist b) Clinical nutritionist c) Occupation therapist d) Rehabilitation counselor

C

Which outcome statement should the nurse use for James' plan of care? a. James will receive oxygen at 2 L/minute per nasal cannula b. James' oxygen saturation will be monitored continuously c. James' oxygen saturation will be greater than 95% on room air d. The client's respiratory function will be stable

C

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? A. Give the client a washcloth to wash the face. B. Move the wash basin farther toward the foot of the bed so the client must reach. C. Have the client brush hair and teeth. D. Move each of the client's hand and arm joints through passive range of motion.

C

The nurse visits with Mr. Rusk and then observes as the UAP assists Mrs. Rusk with her meal. The UAP gives Mrs. Rusk a glass of iced tea of drink. Considering the need for dysphagia precautions, how should the nurse intervene? a) Remind the UAP to keep track of the fluid intake and output. b) Advise the UAP to provide all fluids at room temperature. c) Instruct the UAP to add a thickening agent to all liquids. d) Establish a fluid restriction for the UAP to follow.

C

Which of following is a correctly stated nursing diagnosis for the client with an alteration in fluid & electrolyte status? A. Deficient fluid volume r/t NPO status B. Excess fluid volume r/t heart failure C. Deficient fluid volume r/t difficulty swallowing D. Excess fluid volume r/t physician ordering too many IV fluids.

C

Which statement is the best description of the sleep pattern for a normal adult? a. Sleep problems decreases in middle aged adults b. Most of the sleep cycle is made up of REM sleep c. An adult has four to six sleep cycles, each with NREM sleep and REM sleep, during a normal night's sleep. d. A middle-aged adult requires less sleep than an elderly adult

C

While the nurse is completing the assessment, Janelle begins to cry and laments, "I just knew something would go wrong." How should the nurse respond? a. "This is a minor problem. We'll have you better very soon." b. "You have to expect that problems will occur after surgery." c. "Tell me what is making you feel so upset." d. "Why are you letting this upset you?"

C

Which of the following is a principle of proper body mechanics when moving patients or lifting objects? (Select all that apply.) A. Keep the knees in a locked position. B. Bend at the waist to maintain a center of gravity. C. Maintain a wide base of support. D. Hold objects away from the body for improved leverage. E. Encourage patient to help as much as possible.

C E

Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, serum chloride 105 mmol/L, albumin 4g/dL, AST 30 IU/L, and serum potassium of 3 mEg/L. The nurse reviews the client's lab results. Which lab results is critical and should be reported to the HCP? a) Sodium 140 b) Chloride 105 c) Albumin 4 d) Potassium 3

D

In assessing James' breath sounds, the nurse should ask him to perform which action? a. Hold his breath for 15 seconds b. Observe the color of nailbeds and lips c. Cough deeply after each breath d. Breathe deeply through the mouth

D

In planning morning care for Mr. Mathis, what action should the nurse take? a. Assign the UAP to give Mr. Mathis a complete bed bath, focusing on the right foot. b. Instruct the UAP to give Mr. Mathis a partial bed bath, making sure the right foot is cleansed. c. Encourage Mrs. Mathis to give Mr. Mathis a complete bed bath. d. Ask the UAP to assist Mr. Mathis in taking a completed bed bath.

D

Which of the following should be included in teaching a female client health promotion measures regarding urinary elimination? A. If your urine becomes cloudy or has blood in it, increase your fluid intake B. After urination wipe from the anus toward the urinary meatus C. To strengthen sphincter muscles, do not void when you feel the urge, wait as long as you can. D. Empty the bladder at each voiding.

D

Which instruction should the nurse give to the unlicensed assistive personnel (UAP) for positioning Mr. Mathis' legs? a. Use two pillows and place one lengthwise under each calf b. Let him position himself with pillows until he is comfortable c. Allow him to use the bed controls to markedly flex his knees d. Encourage him to keep his legs flat and not bend his knees

A

Which intervention should be included in the plan of care to provide the nurse with the most accurate information regarding Mrs. Rusk's ongoing nutritional status? a) Instruct the home health aide to weigh the client once a week b) Obtain a prescription for a weekly complete blood count c) Teach Mrs. Rusk how to measure and record her abdominal girth every day d) Advise Mr. Rusk to perform capillary glucose measurements before every meal

A

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipment E. Nutritional intake

A B C D

Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position? a) Respiratory rate b) Blood pressure c) Temperature d) Pulse rate

B

You are recording I&O for Mr. Green at 3 PM. During your shift he vomited 250 ml of yellow liquid, had a liquid stool that measured 100 ml and voided 3 times—150 ml, 200 ml and 100 ml. What was his output on your shift?

800 ml

Chronic Pain is more likely to A. cause parasympathetic symptoms B. occur for 3 months C. be stabbing in quality D. be felt as phantom pain

A

Mr. Olham returns to the clinic after using the CPAP machine at home for 3 months. He reports no improvement in his symptoms and appears disheveled and irritable. He describes sleeping only 3 or 4 hours each night and blames it on discomfort caused by the CPAP machine. The nurse records Mr. Olham's appearance and his complaints in the chart. The nurse considers which information to be subjective data? (Select all that apply.) a. Client states he only sleeps 3 or 4 hours per night b. The client is irritable and yells at his wife when points this out his irritability c. The client has gained an additional five pounds d. The client reports that the CPAP apparatus is uncomfortable e. The client's wife states he has been yawning a lot at home

AB

A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) a. The organism is usually transmitted through the fecal-oral route. b. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. c. Everyone coming into the room must be wearing a gown and gloves. d. While the patient is in contact precautions, he cannot leave the room. e. C. difficile dies quickly once outside the body.

ABC

Which of the following promotes normal defecation? Select all that apply A. Providing privacy for defecation B. Fluid intake of 2000ml/day C. Use of laxatives D. Ignoring the duodenocolic reflex E. Walking 10,000 steps per day

ABE

Which statements reflect potential expected outcomes for nursing diagnosis "disturbed sleep pattern related to stress from new job?" (Select all that apply). a. Client can identify ways to relieve stress during the day and before bedtime. b. Client will report a 50% decrease in night awakenings within 1 week c. Client establishes bedtime rituals, such as having a glass of wine before bed. d. Client maintains a sleep/wake log for 1 month e. Client reports fewer incidences of dozing off during the day

ABE

A patient has been on contact isolation for 4 days because of an infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) A. Teaching how activities such as reading and using crossword puzzles provide stimulation B. Moving him to a room away from the nurse's station C. Turning on the lights and opening the room blinds D. Sitting down, speaking, touching, and listening to his feelings and perceptions E. Providing auditory stimulation for the patient by keeping the television on continuously

ACD

Which of the following would provide meaningful stimuli for a client? Select all that apply. A. A clock or calendar with large numbers B. A radio that is kept on all day at low volume C. Family pictures and possessions D. Interaction with nurse or other patients

ACD

During a home visit a week later, the nurse assesses Mrs. Rusk's nutritional status. Which data indicated the need for the nurse to evaluate Mrs. Rusk further for altered nutrition? (select all that apply) a) The conjunctival sac is pale in appearance when exposed b) Blanching occurs when the fingernail bed is compressed c) The skin over the sternum tents when pinched d) Bowel sounds are auscultated every 5 seconds e) The lips are dry and cracked

ACE

The nurse obtains a health history that reveals Mr. Olham is worried about the pressures of his growing family and new job. He has been unable to maintain his normal exercise routine and has gained 15 lbs. in the last 6 months. Mr. Olham admits he frequently smokes when he cannot sleep. His wife, who has accompanied him on the visit to the clinic, states that his snoring has worsened in both frequency and noises level over the last 3 months. Mr. Olham has even retorted to taking one of his wife's diazepam tablets before bedtime. How does this nurse respond to Mr. Olham's disclosure that he used his wife's diazepam tablets to help him sleep? a. "Do not take more of the diazepam than is prescribed." b. "You should not take someone else's prescription." c. "Let me note that in your chart." d. "Anti-anxiety medication can help you relax enough to fall asleep."

B

The nurse plans to assess Donna for orthostatic vital sign changes. Which action will the nurse take first? a) Assist Donna to a standing position b) Position Donna in a supine position c) Elevate the head of Donna's bed d) Dangle Donna's feet at the bedside

B

The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? A. Age and gender B. Anxiety and fear C. Culture D. Previous pain experience

B

Mr. Mathis is reluctant to move in the bed or move to the chair. He likes his wife to place a pillow under his knee. The nurse performs a physical assessment, which reveals diminished dorsalis pedis pulses bilaterally. Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in Mr. Mathis' legs? a. Encourage Mr. Mathis to use the incentive spirometer 10 times an hour while awake. b. Teach Mr. Mathis to dorsal flex and plantar flex his feet while in the bed and chair. c. Instruct Mr. Mathis to wear sequential compression stockings. d. Advise Mr. Matthew to try not to move and cause pain in his foot wound e. Explain that enoxaparin infections will be administered routinely.

B C E

Which of the following are allowed on a full liquid diet? Select all that apply. A. Scrambled eggs B. Chocolate pudding C. Tomato juice D. Mashed potatoes E. Cream of Wheat cereal

BCE

Which interventions should the nurse add to Mr. Olham's plan of care? (Select all that apply.) a. Encourage an increase in carbs and move the evening meal to 1 hours before bedtime to promote sleep. b. Monitor bedtime food and beverage intake, which might interfere with sleep c. Instruct the client to keep reading material from work at the bedside to review when he awakens. d. Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and to do a quiet activity until becoming sleepy.

BD

Your patient needs an indwelling urinary catheter. Which of the following are important nursing actions? Select all that apply. a. If you find that the drain of the catheter bag has been left open, cleanse it with alcohol prior to refastening it. b. Reassess the continued need for the catheter daily. c. Use clean technique for the insertion of the catheter d. Use good handwashing before and after handling the catheter. e. Secure the catheter to the patient's leg to prevent trauma to the meatus.

BDE

After the nurse explains how the TENS unit soothes pain, Natalie wants to know the best way to apply and use the unit. Which instructions should the nurse include? (select all that apply.) a. After applying the electrodes, set the unit to provide continuous stimulation b. Be sure to use conducting gel or conductor pads when applying the electrodes to the skin c. Remove the electrodes and change sites each time the skin stimulated d. Turn on the unit only when your pain medication does not provide relief e. Clean the skin where the electrodes will be placed and dry thoroughly

BE

A patient is experiencing oliguria (small amounts of urine). Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

C

After further examination and testing by the HCP, Mr. Olham is referred to a surgeon and is scheduled for uvulopalatopharyngoplasty, the removal of tissue in the throat, to treat the obstructive sleep apnea. Mr. Olham is admitted to the hospital, and an apnea monitor is prescribed. The charge nurse should assign Mr. Olham to which room? a. A semi-private room with another client b. A designated isolation room with a double door c. A private room near the nursing station and report room d. A private room at the end of the hall

C

At 3:00 a.m. Mr. Olham awakes and requests a sleeping pill, stating he needs to make sure he gets some sleep the night before surgery. His prescriptions include zolpidem tartrate (Ambien) 5 mg PO at bedtime PRN for sleep. His last respiratory rate while sleeping was 12 with an oxygen saturation level of 89%. His current vital signs are P 80 beats/ min, BP 120/70 mmHg, R 22 breaths/min, T 98.9 degrees F, oxygen saturation 95%. How should the nurse proceed? a. Administer the PRN medication b. Administer oxygen via facemask c. Explain that his oxygen saturation level is too low and it wouldn't be safe d. Administer half of the prescribed dose

C

For ongoing evaluation of Donna's fluid volume status, it is most important to obtain which assessment data? a) Urine color b) Capillary refill c) Body weight d) Skin turgor

C

Two weeks later, the nurse notes a change in Mrs. Rusk's weight. The nurse consults with the nutritionist, who helps complete a 24-hour calorie count. The nutritionist reports to the nurse that Mrs. Rusk, who weight about 110 lbs and is 67 in tall, is consuming 700 calories per day. How should the nurse explain the results of the calorie count to Mr. and Mrs. Rusk? a) Mrs. Rusk is taking in more calories than she needs and may gain weight b) Mrs. Rusk is consuming an adequate number of calories for her height c) Mrs. Rusk's calorie consumption is insufficient and will result in weight loss d) Since Mrs. Rusk's activity is limited, her caloric intake is sufficient to meet her needs

C

What is the correct order of steps for removal of protective barriers after leaving an isolation room? 1. Remove gloves 2. Perform hand hygiene. 3. Remove eyewear or goggles 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side. a. 1, 3, 5, 4, 2 b. 1, 5, 3, 4, 2 c. 1, 3, 4, 5, 2 d. 3, 1, 5, 4, 2

C

When weighing the client with a nursing diagnosis of fluid volume excess, the nurse should weigh the client... A. Two hours after a meal B. At bedtime C. On the same scale each day D. Without clothing

C

Which information is best to use for assessment of the client's functional ability related to nutrition? a) Amount of groceries the client has in the home b) Types of food the client has eaten within the last 24 hours c) The client's ability to feed herself with her left hand d) The husband's schedule for preparing meals

C

Which nursing diagnosis is most relevant to James' current status? a. Excess fluid volume b. Inability to sustain spontaneous breathing c. Impaired gas exchange d. Decreased cardiac output

C

Which of the following is a false statement about pain? A. Pain occurs when the person experiencing it says it does. B. Pain is produced by tissue injury C. Pain produces the same reactions in all persons. D. Pain tolerance can change

C

Which statement made by a parent of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 6 months. D. I'm going to alternate formula with whole milk starting next month.

D

After determining the priority nursing diagnosis, what step should the nurse take next in developing the plan of care? a. Determine the need for client teaching b. Reassess James for any changes c. Implement the priority nursing actions d. Establish goals and expected outcomes

D

After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, James' mother appears worried and nervous and states, "James has never been sick. I am so scared." To encourage the mother to share more about her feelings, how should the nurse respond? a. "James will be just fine. You don't need to worry." b. "I worried just like you when my son was sick." c. "Perhaps you would rather wait outside." d. "It sounds like this has been a very frightening experience for you."

D

The HCP determines that James has a respiratory tract infection and prescribes an oral antibiotic and an oral liquid cough syrup. James' mother obtains the medications at the pharmacy and show them to the nurse. The prescription for the antibiotic reads, "Take 2 pills for the first dose, followed by 1 pill every 12 hours." The mother asks the nurse if this seems right. How should the nurse respond? a. "This sounds like a mistake. Take 1 pill with each dose." b. "2 pills every 12 hours is the usual dose." c. "Let me contact the pharmacist to clarify these directions." d. "A large first dose allows the medication to start working faster."

D

Upon further observation, the nurse describes James' sputum as "tenacious." To what does "tenacious" refer? a. Color b. Odor c. Frequency d. Consistency

D

After several weeks, the bladder training program is unsuccessful in stopping Mr. E's incontinence. Mr. E appears withdrawn and states that he is frustrated at the number of episodes that he is having. Which nursing diagnoses are appropriate for Mr. E? (select all that apply) a. Fluid volume deficit r/t voiding patterns b. Fluid volume excess r/t altered urination c. Risk for uremic syndrome r/t unresolved incontinence d. Risk for impaired skin integrity r/t urinary incontinence e. Ineffective coping r/t inability to control urine leakage

DE

The nurse and nutritionist collaborate to develop a plan of care to improve Mrs. Rusk's nutritional status. The nurse teaches the Rusks about foods that are high in protein and provides them with sample menus. Which breakfast selection(s) are good sources of protein? (select all that apply) a) Oatmeal with a sliced banana b) Pancakes with maple syrup c) Hash browns and an English muffin d) Scrambled eggs and sausage e) Egg, potato and onion omelet

DE

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? A. Isometric exercises B. Administration of low-dose heparin C. Suctioning every 4 hours D. Use of incentive spirometer every 1-2 hours while awake

D

When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A colonoscopy

B

Which documentation best reflects the nurse's objective assessment? a. James reports that he has been coughing up large amounts of sputum b. Frequent deep cough, producing small amounts of pale, yellow sputum c. James seems anxious and short of breath, and he has a constant productive cough d. Cough is frequent, and James produces some yellow sputum when he coughs

B

Which is the most important action for the nurse to perform when assessing bowel sounds? (select all that apply) a. Ask the client is she has lost or gained any weight b. Listen for up to 5 minutes when auscultating for bowel sounds c. Perform a rectal exam d. Inspect the client's abdomen while she is in a semi-Fowler's position e. Begin auscultation in the right lower quadrant

B

Which is the most important approach for the nurse to use when applying a nasal cannula? a. Ensure the cannula tubing stays snugly around the ears and under the chin b. Check that the openings in the nasal prongs are aimed into the nose to prevent skin breakdown c. Never allow the humidifier to run out of water d. Keep some type of padding around the ears and over the cheekbones

B

Which of the following clients may be exhibiting signs of a poor nutritional status? A. Billy White, whose hair is shiny and neither dry or oily. B. Nella Green, whose skin is dry & rough with a few bruises. C. Mrs. Black, whose tongue and mucous membranes are pink and moist. D. Mr. Brown, whose albumin level is 4.2 g/dl.

B

Which of the following substances will promote normal sleep patterns? A. Caffeine B. L-Tryptophan C. Narcotics D. Alcohol

B

Which serum lab value confirms the resolution of James' infection? a. Red blood cell count (RBC) 4.5 million/mm3 b. White blood cell count (WBC) 6,000/mm3 c. Hemoglobin at 12 g/dL d. Hematocrit at 40%

B

Which statement best reflects the nurse's assessment of the fifth vital sign? A. "Do you have any complaints?" B. "Are you having any discomfort right now?" C. "Is there anything I can do for you now?" D. "Do you have any complaints of pain?"

B

Which of the following are physiological effects of exercise on the body systems? Select all that apply. A. Decreased cardiac output B. Increased respiratory rate and depth C. Increased muscle tone, size and strength D. Change in metabolic rate

B C D

What problem often occurs in the elderly and may have contributed to the fluid volume deficit Donna is experiencing? a) Decreased hepatic blood flow b) Decreased drug absorption c) Decreased drug half-life d) Decreased GI acidity

A

Which action should nurse implement prior to applying the sensor to measure the oxygen saturation continuously? a. Determine if James has a latex allergy b. Clean the site with an iodine solution c. "Milk" the capillary blood flow of the site d. Apply gauze padding to protect the skin

A

Donna's intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Donna may develop fluid volume excess. Which assessment is important for the nurse to perform? a) Auscultate the client's breath sounds b) Measure the client's tympanic temperature c) Compare the client's muscle strength temperature d) Ask the client if she is experiencing any syncope

A

Which assessment finding further supports diagnosis? a. Restlessness and fatigue b. Skin is warm and flushed c. Complaints of being thirsty d. Blood pressure of 102/62 mmHg

A

Which assessment is most important for the nurse to perform? a. Auscultate bowel sounds b. Measure abdominal girth c. Observe incisional staples d. Measure blood pressure

A

Because Mr. Mathis stayed in bed for a week prior to hospitalization and has had only limited ambulation while in this hospital, the nurse is concerned about muscle atrophy. Which is the best approach for the nurse to prevent muscle atrophy? a. Teach Mr. Mathis to perform exercises such as gluteal sets and quadriceps sets five times every 2 hours while awake. b. Teach Mr. Mathis to perform active range of motion exercises of his arms and legs twice a day. c. Instruct the UAPs to perform passive range of motion exercises twice a day. d. Instruct the UAPs to reposition Mr. Mathis in bed every 2 hours while he is awake.

A

James' respiratory rate is 36 breaths/min. How should the nurse describe James' respiratory pattern? a. Eupnea b. Bradypnea c. Tachypnea d. Orthopnea

C

The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis. Which action requires the nurse to intervene? a. Palpating bilateral pedal pulses b. Assessing the capillary refill in the great toe c. Assessing the Homan's sign in bilateral extremities d. Applying light pressure in ankles to determine edema

C

The antitussive medication label reads, "take 2 teaspoonfuls every 4 hours as need." The nurse gives James some mL medication cups and teaches James and his mother how to pour the medication into the mL cup. To what mL level should the medication be poured?

10

You are recording I&O for Mr. Green at 3 PM. He was NPO for breakfast. At lunch he had ½ cup of jello, a bowl of soup (6 ounces) & a can of soda (12 Ounces). He drank 1 cup of water after lunch. He had 800 ml of IV fluids. What was his intake on your shift?

1700

The nursing staff continues with the bladder-training program, but Mr. E's incontinence shows little improvement. Since the bladder training has not been successful, the nurse obtains a prescription to apply a condom catheter. Mr. E is able to ambulate with assistance. In what order should the prescribed condom catheter be applied to Mr. E? (arrange the options in the order they should be performed with the first action on top and last on the bottom) 1. Apply skin protecting cream and allow it to dry 2. Wrap the adhesive spirally around the shaft of the penis 3. Clean and dry the penis 4. Attach a large leg drainage bag to reduce the frequency of bad emptying while the client is ambulatory 5. Place the rolled condom over the glans penis and unroll it gently over the penis

31254

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy

A

A nursing assistant asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? A. "As long as we use proper body mechanics, no one will get hurt." B. "The patient only weighs 125 lbs. You don't need my assistance." C. "Call the lift team for additional assistance." D. "The two of us can lift the patient easily."

A

Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. Which change in Donna's pulse will the nurse anticipate? a) Increase in rate and volume b) Decrease in rate and volume c) Increase in rate, but no change in the volume d) Decrease in rate, but no change in volume

A

During the nurse's initial interview, Natalie shares info about her home, career, and family. The nurse evaluates the information to determine psychosocial factors that may impact pain management. 1) Which information obtained by the nurse is most likely to influence Natalie's perception of her pain? a. Natalie's younger child is an infant who feeds every 3 hours b. Natalie's 4 year old enjoys being the "big brother" to his baby sister c. Natalie was a first grade teacher before having children but now stays home d. Natalie's parents live in the same neighborhood and often help with the children

A

What impact does this fluid intake have on Janelle's bowel patterns? a. This inadequate fluid intake has contributed to her constipation b. This sufficient amount of fluid intake has not affected her bowel patterns c. This large amount of fluid intake has helped keep her feces soft d. Intravenous fluids have little or no impact on intestinal contents and bowel patterns

A

Following an episode of incontinence, the nurse washes the client's perineal area with mild soap and water and applies a water-repellent ointment to the skin. Mr. E's wife is present and the nurse uses this opportunity to educate her about proper skin care to prevent breakdown. Which of the following statements made by Mrs. E indicated that teaching has been effective? a. "Washing the area with mild soap and water followed by ointment can help protect my husband's skin" b. "I should not use any type of soap around his buttocks or groin" c. "I should not apply lotions and ointments because it could increase the risk of skin breakdown." d. "I should massage any reddened areas if I notice them."

A

How should the nurse explain the mechanisms that causes the skin to become reddened from prolonged exposure to cold? a. Reflex vasodilation occurs following the initial vasoconstricting effects of cold b. Cold causes a numbing sensation, which interferes with circulation at the site c. Debris from necrotic tissue collects at the site of vasoconstriction, causing inflammation d. Intradermal tissue blisters occur as the result of the damage caused by exposure to cold

A

In teaching methods to promote sleep habits at home, the nurse instructs the client to A. Use the bedroom only for sleep or sexual activity B. Eat a large meal 1 to 2 hours before bedtime C. Exercise vigorously before bedtime D. Stay in bed if sleep does not come after ½ hour

A

Mr. Mathis tells the nurse, "My sweetheart and I have never been apart during on 55-year marriage". What action should the nurse implement to help reduce Mr. Mathis' anxiety during the admission process? a. Explain the room environment to Mr. and Mrs. Mathis b. Ask Mrs. Mathis if she would like to rest in the waiting room. c. Ask Mr. Mathis is he would like a prescription for an antianxiety medication. d. Reassure Mr. and Mrs. Mathis that everything will be okay.

A

Mr. Olhams' surgery is completed without complications. After a 2-hour stay in the post anesthesia unit, he returns to him. The next day, the nurse observes the following vital signs: Mr. Olham's heart rate drops from 80 bpm to 65 bpm while he is sleeping. His oxygen saturation remains greater than 95% with regular respirations of 16 to 20 per minute. Which action should the nurse implement? a. Document this expected finding b. Contact the HCP about this abnormality c. Recommend the application of a cardiac monitor d. Increase vital sign monitoring from evert 8 hours to every 4 hours

A

Mrs. G, a 42 year old Mexican-American patient, refuses to eat the hospital prepared food and eats only the flour tortillas, beans and rice brought in by her family. The nurse's first action should be to A. Determine whether Mrs. G's diet meets her daily nutritional needs. B. Find out how to add meat to her diet for necessary protein intake. C. Tell Mrs. G that the hospital prepares balanced meals and it would be better for her to eat what is on her tray. D. Explain to Mrs. G how she can choose items of preference from the hospital menu.

A

Since James has a productive cough, HCP requests that a sputum specimen be obtained and sent to the lab for culture and sensitivity. When assisting James to obtain a sputum specimen, what action should the nurse take? a. Instruct James to cough deeply from the chest and spit into the specimen cup b. Gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx c. Insert a soft-tipped catheter through the nares to suction secretions d. Use a hard-tipped Yankauer catheter device to remove oral secretions

A

The HCP prescribes a complete blood count (CBC) as a part of diagnosis workup on James. Which is the best explanation for the HCP's prescriptions? a. A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults b. A CBC is obtained so that the HCP can rule out the possibility of appendicitis c. Anemia is suspected, so a CBC is a drawn to measure hemoglobin and hematocrit d. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment

A

The most effective nursing action for controlling the spread of infection is a. thorough hand washing b. wearing gloves and masks when providing direct patient care c. implementing appropriate isolation precautions d. administering broad spectrum prophylactic antibiotics

A

The nurse auscultates for Janelle's bowel sounds and hears faint gurgling sounds after 3 minutes. Which assessment finding should the nurse document? a. Hypoactive bowel sounds b. Normal bowel sounds c. Paralytic ileus d. Reduced peristalsis

A

The nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should the nurse take? a. Record the presence of clear breath sounds b. Tell James' mother that his lungs are still congested c. Assist James to cough to clear his lungs and listen again d. Notify the HCP of the abnormal lung sounds

A

The nurse explains to Janelle that she has developed constipation, probably as the result of a number of factors. Janelle has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 mL. The nurse explains risk factors that can contribute to constipation. Which postoperative medication is most likely to contribute to constipation? a. Morphine sulfate, an opioid analgesic b. Ibuprofen, a non-opioid analgesic c. Promethazine, an antiemetic d. Cefazolin, and antibiotic

A

The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely: A. Increase the patient's risk for falls and injuries B. Result in less stress on the patient's joints. C. Decrease the amount of work required for patient movement. D. Allow for mobility in spite of the aging effects on the patient's joints. (Passive = doing it for them, passive is better than nothing but active is better)

A

The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? a) Count the client's radial pulse rate b) Remove the blood pressure cuff c) Help the client change positions d) Assess for an auscultatory gap

A

The patient has a nursing diagnosis of risk for constipation related to immobility and decreased fluid intake. Which of the following is the appropriately stated projected outcome for this diagnosis? A. Patient will have a bowel movement every other day. B. Patient will drink 2000 ml of fluid every day C. Patient will not be constipated D. Patient will be turned every 2 hours

A

After receiving oxygen for a short while, James is much less dyspneic. The nurse notes that the oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%. What immediate actions should the nurse implement? (select all that apply) a. Reposition the finger clip and obtain another reading b. Assess James for signs and symptoms of respiratory distress c. Encourage James to begin coughing and deep breathing d. Increase the oxygen flow to 3 to 4 L/min e. Notify the HCP immediately

A B C

James and his mother return to the HCP's office 1 week later, after James completes the course of antibiotic therapy. When assessing James' breath sounds, where should the nurse listen first? a. Lung bases b. Lung apices c. Aortic site d. Pulmonic site

B

The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient that from a nutritional point of view, the patient should (Select all that apply.) A. Maintain body weight in a healthy range. B. Increase physical activity. C. Increase intake of meat and other high-protein foods. D. Keep saturated fat intake to 10% or less. E. Choose and prepare foods with little salt.

ADE

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse plan to do first? A. Start an IV of Normal Saline B. Obtain blood for serum electrolytes C. Offer the woman foods high in sodium & potassium D. Administer a medication to stop vomiting

B

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Which of the following is the proper order of steps for the "Timed Get-up and Go Test" (TGUGT)? 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support. A. 3, 1, 2, 5, 6, 4 B. 2, 1, 3, 5, 6, 4 C. 1, 2, 3, 6, 5, 4 D. 1, 2, 3, 5, 6, 4

B

After establishing priorities, the nurse should take which action next in developing Mrs. Rusk's plan of care? a) Analyze data b) Establish goals c) Complete an assessment d) Implement interventions

B

After further conversation with James' mother, the nurse needs to leave the room to assess another client. Which action by the nurse demonstrates the use of trust in the nurse-client relationship? a. Teaching James and his mother how to read the oximeter b. Returning to the room at the time promised c. Offering the mother reassurance that James is stable d. Providing a phone so that James' mother can call home

B

As a part of the physical assessment of Mr. Mathis, the utilizes the Braden scale.The nurse explains to the UAP that the Braden Scale is used to measure which client parameter? a. Neurological status b. Risk for pressure sores c. Risk for thrombophlebitis d. Condition of the oral mucosa

B

As part of the admission interview, the nurse asks Mr. Mathias and his wife how they would like to be addressed by the staff. They reply that until they are more comfortable, they prefer to be called "Mr. and Mrs. Mathias." As the interview continues, Mr. Mathis tells the nurse that he has never been hospitalized. He appears anxious and frequently turns to his wife for reassurance. Which information is most important for the nurse to obtain in the initial assessment? a. "Is there anything you would like to ask your healthcare provider?" b. "Tell me about concerns you have about being hospitalized." c. "We give good care to all of our clients in this hospital." d. "Your healthcare provider has chosen the best hospital in the city."

B

Because of significant concerns about financial problems a middle aged client complains of difficulty sleeping. Which of the following would be an appropriate outcome for the nursing diagnosis, Insomnia related to anxiety response secondary to financial concerns AMB difficulty falling asleep, c/o fatigue on awakening? By day 5, Mr. D will A. Sleep 8 to 10 hours per day B. Report falling asleep within 20-30 minutes—how will you know the insomnia is better? C. Have a plan to pay his bills D. Will begin an activity that will keep him busy in the evening

B

Donna's daughter reports that her mother usually weighs about 137 lbs (62.14 kg) and is 5'3" (160 cm) in height. The nurse weighs Donna and obtains a measurement of 60 kg. The nurse explains to Donna's daughter that Donna has lost approx. how many pounds? a) 3 b) 5 c) 4 d) 7

B

During shift report, the nurse learns that an older female patient has had several episodes of incontinence when hurrying to the bathroom. Which of the following nursing diagnoses is most likely to apply to this patient? A. Stress urinary incontinence small amounts when you laugh, cough B. Urge urinary incontinence large amounts C. Functional urinary incontinence can't get into bathroom D. Total urinary incontinence

B

Further assessments and testing are ordered to assist in the diagnosis of constipation. An upper GI series (Barium swallow) is ordered. Janelle appears nervous, and asks the nurse to explain this procedure. Which response by the nurse accurately describes a barium swallow? a. Barium is inserted into the rectum and a series of x-rays are taken b. A barium liquid is swallowed and a series of x-rays are taken c. A scope is inserted into the mouth, down the throat, and into the stomach d. A flexible scope is inserted into the anus that visualizes the rectum and colon

B

In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her fluid and nutritional status. The nurse plans interventions related to Mrs. Rusk's dysphagia. To which member of interprofessional team should the nurse refer Mrs. Rusk? a) Care manager b) Speech therapist c) Registered dietician d) Geriatric nurse practitioner

B

Natalie returns to the pain clinic in a week and reports that her pain has worsened. The pain management physician recommends the use of a transcutaneous electrical nerve stimulator (TENS) unit and prescribes a schedule IV opioid analgesic. Natalie appears confused when the physician explains the TENS unit. Which explanation by the nurse best describes the how the TENS unit soothes pain? a. Continuous high-pressure stimulation of the pain nerve fibers are blocked b. It sends stimulating pulses though the skin, to block pain signals from reaching the brain c. Electrodes are placed at pressure points to measure biofeedback and reduce stress d. Needles are inserted to stimulate specific points in the body

B

Since Mr. Ellis now voids spontaneously without recognizing the need to void, how should the nurse document his current urinary pattern in the medical chart? a. Polyuria b. Incontinence c. Retention d. Oliguria

B

The assessment scale results help the nurse to recognize that Mr. Mathis is at risk for impaired skin integrity because of decreased nutrition and mobility. The nurse develops a plan of care with the UAP. Which nursing action should be included in the plan? a. Reposition Mr. Mathis in bed to a 90 degree side-lying position every 2 hours. b. Reposition Mr. Mathis in bed from supine to a 30 degree side-lying position every 2 hours. c. Place a hydrocolloid dressing on Mr. Mathis' heels. d. Massage Mr. Mathis' reddened, bony prominence with lotion every 2 hours.

B

The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide? a. Wear clean gloves to carry the specimen to the lab b. Wear clean gloves to place the specimen cup in a biohazard bag for transport c. Wear gloves and a gown for the best production d. Wash hands after carrying the cup to the lab

B

The liquid cough syrup is labeled as an antitussive. The nurse explains that this medication should have what effect? a. Liquefy the respiratory secretions b. Reduce the frequency of the cough c. Decrease any pain with coughing d. Prevent nausea due to the sputum

B

The nurse also develops a dietary teaching plan to reduce the risk of constipation. Which dietary selection should the nurse encourage Mr. Mathis to eat? a. Peanut butter and jelly on white bread, crackers, and a diet cola b. Chicken Caesar salad with a whole wheat roll and skim milk c. Grilled cheese on rye bread, and sweet tea d. Fried chicken with coleslaw and a mineral water

B

To assess the quality of Natalie's pain, the nurse asks which question? a. "On a scale of 0 to 10, how would you rate your pain?" b. "What word best describes the pain you are experiencing?" c. "What actions do you take to relieve the pain?" d. "What do you fear most about your pain?"

B

To determine the etiology of Natalie's anxiety, what is the priority nursing intervention? a. Refer the client to the clinic social worker b. Continue the interview with the client c. Review the HCP's notes d. Recognize that pain causes anxiety

B

To measure capillary refill, the nurse must first perform which action? a. Count the radial pulse rate b. Compress the nailbed of one finger until it blanches c. Obtain a healthcare provider's prescription d. Elevate the extremity to be assessed

B

What does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing

B

When Donna was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity. Now that Donna is taking oral fluids well, what action should the nurse implement? a) Notify the HCP that a prescription to continue intake and output measurement is needed b) Continue the measurement of the client's fluid intake and output c) Stop measuring the client's fluid intake and output d) Measure the client's fluid output, but discontinue measuring fluid intake

B

When applying a nasal cannula in the ED, what action is most important for the nurse to implement to ensure client safety? a. Ensure the bed is in low position and the call light is within reach b. Determine that all electrical equipment in the room is functioning correctly and is properly grounded c. Use aseptic technique to prevent contamination when applying the cannula d. Use petroleum gel on the cannula prongs to prevent irritating the nostrils

B

The nurse observes that Janelle's abdomen is firm and distended. The nurse performs an abdominal assessment. Which sequence should the nurse perform the abdominal assessment? a. Auscultation, inspection, percussion, palpation b. Inspection, palpation, auscultation, percussion c. Inspection, auscultation, percussion, palpation d. Auscultation, percussion, inspection, palpation

C

Because of James' dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for supplemental oxygen, which assessment is most important for the nurse to perform? a. Measure oxygen saturation b. Auscultate breath sounds c. Measure capillary refill d. Observe chest excursion

C

Before notifying the healthcare provider of the data reported by the nutritionist, what information is most important for the nurse to obtain? a) Type of vitamin supplement the client is taking b) Percent of diet composed of carbohydrates c) Client's calculated body mass index d) Daily fat gram intake by the client

C

In developing a plan of care, the nurse consults with Mr. Mathis to identify a short-term goal. Which goal is correct for Mr. Mathis' diagnosis of impaired physical mobility? a. The client will transfer to the chair with assist of one person b. The nurse will reposition the client every hour while client is awake c. The client will sit in the chair for each meal beginning on the day of admission d. The nurse will assist the client to ambulate in the hall by the second hospital day

C

Interventions for the client with actual or potential sensory alterations include all of the following except A. Promoting optimal function of existing senses B. Preventing additional sensory loss C. Promoting client's acceptance of dependency D. Controlling the environment to create meaningful sensory stimuli

C

James' mother further states that she is worried her 2-year-old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter? a. "If you breastfed your daughter, she will have a natural immunity." b. "She will be protected from illness if she has had all her scheduled vaccinations." c. "There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms." d. "She is young enough that she will not be as ill as her brother. There is nothing serious to worry about."

C

James' mother states that this is the third time in recent months she has brought him to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections James has had within the past year. Why does the nurse ask this? a. To assess for suspected child neglect or abuse b. To explore the possibility of antibiotic resistance developing c. To assess for a possible immune deficiency disorder d. To explore the need for a primary care provider to avoid ED visits

C

Mr. Ellis states that prior to his stroke, he would get up five or six times during the night to empty his bladder but that he was able to control the urge long enough to make it to the bathroom. How should the nurse describe the urinary pattern that Mr. Ellis is describing? a. Dysuria b. Frequency c. Nocturia d. Diuresis

C

Mr. Mathis states the pain level in his right foot is 8 on a scale of 1 to 10. He says he has been favoring his foot by staying in bed the past week. When care is planned for Mr. Mathis, which nursing diagnosis should take priority? a. Risk for caregiver role strain b. Risk for social isolation c. Impaired physical mobility d. Imbalanced nutrition: more than body requirements

C

The nurse also encourages Mr. Rusk to prepare high calorie snacks for Mrs. Rusk. Mr. Rusk states that his wife loves applesauce and asks if this a good snack choice. How should the nurse respond? a) "Do not offer her applesauce because it does not provide very many calories." b) "Processed foods such as applesauce are often very high in sodium." c) "Provide applesauce since she likes it, along with higher calorie snacks." d) "Applesauce is an excellent source of nutrients and calories."

C

The nurse determines that Janelle's inadequate fluid intake, decreased mobility, and opioid use are significant factors in the development of her constipation. Which nursing diagnosis should the nurse include in Janelle's plan of care? a. Risk for constipation and lack of fluid intake b. Inadequate fluid intake, resulting in constipation c. Constipation related to surgery and anesthesia d. Constipation manifested by decreased bowel sounds

C

Which behavior does Natalie exhibit, that the nurse documents as objective signs of acute pain? a. States pain level of 5 out of 10 b. Complains of shortness of breath c. Difficulty concentrating d. Frequent grimacing

D

Janelle responds, "I did everything my HCP told me to do. The surgery must have caused this. They must have made a mistake." Which explanation by the nurse is accurate? a. Refer the client to the surgeon to answer any questions about the surgical outcome. b. Advise the client that abdominal hysterectomy should not cause decreased peristalsis, so an error must have occurred during surgery. c. Offer the client emotional support as she copes with this adverse outcome of surgery. d. Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved.

D

Janelle tells the nurse, "I hate hospitals because nobody ever tells you what's happening, and you end up with all these things going wrong." Which response by the nurse will encourage continued verbalization by the client? a. "All the nurses are very busy here, and they are doing the best job they can." b. "You should write down your questions so you can get some answers." c. "I will happy to tell you everything that's happening, so nothing else will go wrong." d. "It sounds as if you have had another experience that did not go well."

D

Natalie states that she has also been applying a cold pack an hour at a time to help heal her back as quickly as possible. a. The cold pack provides pain relied but does not heal the injury b. The cold application should be alternated with the heating pad c. Cold reduces inflammation and prevents tissue swelling d. The cold pack should only be applied for approx. 20 minutes at a time

D

Natalie tells the nurse that she has an electric heating pad at home that she used when she sprained her ankle. Which response by the nurse is accurate? a. "Warm moist compresses are a better choice bc there is less chance of injury to your skin." b. "A heating pad is more effective than moist compresses bc it will penetrate more deeply into the muscles." c. "Heating pads provide dry heat, which promotes vasoconstriction, reducing any muscle swelling that has occurred." d. "The dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation."

D

The HCP has prescribed the thigh-high antiembolic hose for Mr. Mathis. The nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of thrombophlebitis that should be reported to the HCP? a. Negative for paresthesia b. Decreases hair growth in lower legs c. Negative for pallor d. Unilateral calf edema

D

The nurse assesses James' vital signs. His respirations are rapid and shallow. Which is the best technique for the nurse to use to assess James' respirations accurately? a. Observe chest expansion for 15 seconds and multiply by 4 b. Encourage James to breathe as deeply and slowly as possible. c. Watch for nasal flaring and count the air exchanges with each movement. d. Place a hand on James' upper abdomen and observe the rise and fall of the chest.

D

The nurse considers interventions to include in the plan of care. Before implementing any interventions, what actions is most important for the nurse to take? a. Place a copy of the plan of care in the client's chart b. Evaluate the client's response to the interventions c. Review interventions in a care plan manual d. Discuss the plan of care with the client

D

The nurse continues to assess the client and observes that Courtney's skin tents when a fold of skin over her sternum is pinched. Which action should the nurse implement? a) Confirm this finding by pinching the skin on her hand b) Notify the healthcare provider that client is now retaining fluid c) Advise Donna that the fluid deficit seems to be worsening d) Document the presence of inelastic skin turgor

D

The nurse provides client teaching on the effects of diet, exercise, stress reduction medications, and the environment on sleep patterns. Which statement by Mr. Olham reflects correct client teaching? a. "It is a myth that drinking warm milk before bedtime can help me sleep." b. "Cigarette smoking works as a depressant and can help me relax." c. "I should take naps during the day if possible." d. "Changes in my environment can make it difficult to sleep."

D

The speech therapist is consulted and makes a home visit to evaluate Mrs. Rusk. The therapist determines that dysphagia precautions are needed. The nurse and the unlicensed assistive personnel (UAP) arrive at the home shortly after the therapist's evaluation is completed. The UAP prepares to assist Mrs. Rusk with her noon meal and with her personal care. What instruction should the nurse provide to the UAP? a) Keep the client in a semi-Fowler's position while bathing her and also while assisting her with her mail. b) Help feed the client first and then allow her to rest with the head of the bed lowered for 1 hour before bathing her. c) Provide assistance with the meal and then lower the head of the bed to bathe the client and change the bed linens. d) Bathe the client first and then place the client in a high Fowler's position during and after the meal.

D

To help manage Mr. E's incontinence, the nurse initiates a bladder training program. Which instruction should the nurse provide to the unlicensed assistive personnel (UAP) who will be helping care for Mr. E? a. Restrict oral fluids to 1,000 mL daily in evenly divided amounts b. Offer warm coffee, cocoa, or tea every 2 hours while awake c. Limit client socialization until voiding patterns are established d. Remind the client to void every 2 hours while awake and to call for assistance to the bathroom

D

To promote sleep for a hospitalized client, which intervention should the nurse implement? a. Avoid performing the prescribed assessments every 4 hours during the night b. Withhold the client's pain medication during the day to decrease napping episodes. c. Ensure that the client's room is kept completely dark during the night with no outside lighting d. Close the door to the client's room whenever possible to decrease the noise level and light coming into the room.

D

Upon returning to the room, the nurse assesses James' cough. Which documentation reflects subjective data? a. James' respirations are 36 breaths/min b. James appears anxious by repeatedly reaching for his mother's hand and asks, "Am I going to be okay?" c. James' mother is present in the room d. James reports that he is coughing a lot

D