The Nursing Process

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce? "Make sure to get sunlight exposure daily." "Do not limit your activity between flare-ups." "Stop the steroid when your symptoms subside." "Monitor your temperature for signs of infection."

"Monitor your temperature for signs of infection."

A client with end-stage liver cancer states that no extraordinary measures are to be used to prolong the client's life. The client asks the nurse about the necessary steps to make these wishes known and legally binding. Which response by the nurse would be most appropriate? "You're talking about euthanasia, which I don't agree with." "I'm not really able to say because that's a legal question." "Let's talk to the charge nurse about getting your wishes in an advance directive." "Here's the Patient's Bill of Rights, which should tell you what you need to know."

"Let's talk to the charge nurse about getting your wishes in an advance directive."

A client with a history of duodenal ulcers states to the nurse, "I take antacids once in a while to relieve the pain." Which statement by the client should be reported immediately? "I have this gnawing pain in my belly a few hours after I eat that causes nausea." "My bowel movements have been sticky and black." "I've had a lot more pressure at work lately." "I have this bad taste in my mouth after taking my antacid and feel like I have to vomit."

"My bowel movements have been sticky and black."

A nurse is reviewing the care plan of a client who has been receiving an intravenous solution. What appropriate expected outcome for this client should the nurse expect to find on the care plan? "Monitor fluid intake and output every 4 hours." "The client remains free of signs and symptoms of phlebitis." "Edema and warmth are noted at I.V. insertion site." "There is a risk for infection related to I.V. insertion."

"The client remains free of signs and symptoms of phlebitis."

A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as 0800 and 1200 0800 and 2200 0800 and 2000 800 and 2200

0800 and 2000

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response? Have the child sign a "Disclosure of Health Information" form prior to giving the child the information. Tell the client's child the blood glucose level because this test is performed on the nursing unit. Ask the client's child if she has her parent's permission to access the parent's health information. Explain that this information cannot be disclosed without the client's permission.

Explain that this information cannot be disclosed without the client's permission.

The nurse notes that a client's blood glucose level is increased. The nurse plans to inform the physician by phone. Which technique should the nurse use to communicate verbally to the physician? CBE EMAR SBAR SOAP

SBAR

A nurse who works on a psychiatric unit arrives to work disheveled, unkempt in appearance, and smelling of alcohol. What is the best approach for the nurse's colleague on the night shift to manage this situation? Support the coworker because the nurse in question is a professional and responsible. Monitor the behavior during the shift and follow up if anything is forgotten with client care or shift responsibilities. Encourage the nurse to report in as sick and hope the unit can get a replacement. Immediately report the concern to the appropriate leader or manager in charge.

Immediately report the concern to the appropriate leader or manager in charge.

After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client? Absence of the gag reflex Difficulty swallowing Arm and leg weakness Inability to speak clearly

Inability to speak clearly

A client is experiencing mild diarrhea through the colostomy. Which instruction is correct? Increase intake of bananas. Eat prunes. Increase lettuce intake. Drink apple juice.

Increase intake of bananas.

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? Decide on a treatment plan if the client cannot. Advise clients not to execute an advance directive because it limits treatment options. Inform the client or legal guardian of the right to execute an advance directive. Respect individuals' moral rights.

Inform the client or legal guardian of the right to execute an advance directive.

A nurse is caring for a client who is awaiting surgery for a hip fracture. Which nursing intervention has the highest priority when providing skin care for this client? Keep the skin clean and dry without using harsh soaps. Rub moisturizing lotion over pressure areas. Gently massage the skin around pressure areas. Change the bed linens frequently for an incontinent client.

Keep the skin clean and dry without using harsh soaps.

A nurse collects the following client data: impaired coordination, decreased muscle strength, and limited range of motion. Which intervention should the nurse give highest priority? Perform passive range-of-motion exercises. Place personal items within reach. Assist with activities of daily living (ADLs). Encourage participation in self-care.

Place personal items within reach.

A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? Impaired physical mobility related to surgery Acute pain related to surgery Risk for aspiration related to general anesthesia Deficient fluid volume related to blood and fluid loss from surgery

Risk for aspiration related to general anesthesia

The nurse assists in developing a list of nursing diagnoses for a client. This list should include: factors influencing the client's problem. actions to achieve goals. expected outcomes. nursing history.

factors influencing the client's problem.

A licensed practical nurse (LPN) is assisting a registered nurse in caring for a primigravida client with acquired immunodeficiency syndrome (AIDS) who is at term and in early labor. When providing care to this client, which area would the LPN focus on as the priority? fetal oxygenation fluid balance crisis intervention infection control measures

infection control measures

An HIV-positive client discovers that their name is published in a report on HIV care prepared by the nurse. The client strongly opposes this and files a lawsuit against the nurse. Which offense has this nurse committed? negligence of duty defamation unintentional tort invasion of privacy

invasion of privacy

The nursing team is caring for clients on a clinical unit when the fire alarm sounds. Which nurse on the team acts most appropriately to contain a fire? the nurse who closes all the inside doors the nurse who stays with an immobile client the nurse who returns to the nurses' station the nurse who searches for signs of smoke

the nurse who closes all the inside doors

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask? How long have you worked on this floor? Which task would you prefer to perform? What is your highest educational level? Are you comfortable performing the tasks assigned?

Are you comfortable performing the tasks assigned?

A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client? Imbalanced nutrition: Less than body requirements related to decreased intake Ineffective cardiopulmonary tissue perfusion related to hyperventilation Deficient fluid volume related to nausea and vomiting Excess fluid volume related to intracellular fluid shift

Deficient fluid volume related to nausea and vomiting

A nurse is assigned to care for a client in the immediate postoperative recovery phase. Which data collection takes priority during the initial assessment? dressings, drains, and intake and output level of consciousness and presence of reflexes vital signs, presence of reflexes, and intake and output airway, respiratory rate and depth, other vital signs, and skin color

airway, respiratory rate and depth, other vital signs, and skin color

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce? "Do not limit your activity between flare-ups." "Make sure to get sunlight exposure daily." "Stop the steroid when your symptoms subside." "Monitor your temperature for signs of infection."

"Monitor your temperature for signs of infection."

A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client? Disturbed thought processes Impaired physical mobility Activity intolerance Hyperthermia

Hyperthermia

A client gave birth vaginally to a healthy, full-term baby girl 2 hours ago. When gathering data on this postpartum client, which finding would the nurse report immediately? gush of vaginal blood when the client stands tachycardia accompanied by hypotension reports of incisional site pain blood stain 2 inches (5 cm) in diameter on the abdominal dressing

tachycardia accompanied by hypotension

A 1-year-old child is diagnosed with a congenital cardiac defect after cardiac catheterization. The parents have expressed concern about activities at home. Which response by the nurse would be best when reinforcing education with these parents? "The child will only be able to play alone." "Discipline and limit-setting need to be relaxed to reduce stress and crying." "Allow the child to play and be active as long as the child doesn't get fatigued." "You'll have to establish strict discipline so that the child learns what activities are limited."

"Allow the child to play and be active as long as the child doesn't get fatigued."

A client expresses a desire to walk to the lobby for discharge to home. The unlicensed assistive personnel (UAP) tells the client that all clients being discharged need to be transferred to the lobby by wheelchair. How will the nurse best respond to protect the client's right of care? Select all that apply. "The client has the right to walk to the lobby for discharge." "An employee will accompany you to the lobby if you choose to walk." "Clients are at risk for falls if they do not use the wheelchair when being discharged." "At this hospital clients must be discharged by wheelchair to the lobby." "It is the hospital policy for the client to use a wheelchair to the lobby when being discharged."

"An employee will accompany you to the lobby if you choose to walk." "The client has the right to walk to the lobby for discharge."

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The student nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. The nursing instructor asks the student which step of the nursing process is he performing. How would the student respond? "Implementation" "Planning" "Data collection" "Evaluation"

"Data collection"

After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which action by the nurse is most appropriate? Wait to hear if the nurse manager will offer some advice. Enter the information tomorrow stating it is a late entry. Call the unit and dictate the entry to another nurse. Call and ask the nurse to leave a blank entry for completion tomorrow.

Enter the information tomorrow stating it is a late entry.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Toileting self-care deficit Excess fluid volume Urinary retention Fear

Excess fluid volume

A female client has a fractured left hip. Her left leg is in Buck's traction while the client is being prepared for a hip pinning. What should the nurse plan to do when inserting an indwelling catheter? Instruct the client to turn on her right side with both legs flexed. Add tape to the catheter tray for taping the indwelling catheter to the client's abdomen. Choose a No. 12 French catheter. Instruct the client to deep breathe during catheterization.

Instruct the client to deep breathe during catheterization.

A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best? Ask the nurse why she's accessing the medical record and ask her to leave the client care area. Notify security and the client's physician of the incident. Notify the charge nurse and nursing supervisor of the incident. No action is necessary.

Notify the charge nurse and nursing supervisor of the incident.

The nurse on a neurovascular unit is caring for a client with a head injury. When obtaining vital signs the nurse documents a BP of 180/62 mm Hg and heart rate of 48 beats/min. What intervention by the nurse is essential at this time? Monitor vital signs every 15 minutes. Monitor electrolyte studies. Notify the health care provider. Administer furosemide 40 mg IV.

Notify the health care provider.

A nurse in a long-term care facility consistently administers clients' medications 60 to 90 minutes after the scheduled administration time. The nurse also leaves scheduled treatment procedures for nurses on the next shift to complete. Which would be an appropriate strategy for this nurse to pursue? Delegate lower priority interventions to the nurse on the next shift. Seek input and direction on time management and priority setting. Request the assistance of an unlicensed assistive personnel. Discuss the need to work with fewer clients on the unit.

Seek input and direction on time management and priority setting.

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record? refraining from entering the client's full name ending each entry with a signature and title refraining from entering the full names of care providers leaving one line blank before each new entry

ending each entry with a signature and title

During the planning step of the nursing process, the nurse establishes short- and long-term goals. determines the client's goal achievement. writes a statement about the client's health problem. gathers objective data.

establishes short- and long-term goals.

A nurse working on a critical care unit was informed by a client with multiple sclerosis that the client did not wish to be resuscitated in the event of cardiac arrest. The client is no longer able to express their wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may cause paternalism confidentiality deception ethical distress

ethical distress

A nurse finds that a colleague is intoxicated while on duty. What appropriate action would the nurse take? advise the colleague to go home ask the colleague if he or she is intoxicated ask another nurse if the colleague appears intoxicated inform the nursing supervisor

inform the nursing supervisor

The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called? grace period alternative dispute resolution discovery rule statute of limitation

statute of limitation

A nurse is assisting with the prenatal screening of a pregnant client with diabetes. The nurse should be aware that the client is at increased risk for which complications? Select all that apply. spontaneous abortion Rh incompatibility gestational hypertension placenta previa stillbirth

stillbirth gestational hypertension spontaneous abortion

A nurse has forgotten the computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage? "I will write down my password for you until you can reset your password." "Would you like me to help you contact information services to reset your password?" " I will contact information services for you to reset your password." "I will log into the computer for you until you can reset your password."

"Would you like me to help you contact information services to reset your password?"

A client at 32 weeks' gestation is leaking amniotic fluid and placed on an electronic fetal monitor. The nurse determines that the monitor strip indicates uterine irritability, with contractions occurring every 4 to 6 minutes. The health care provider prescribes magnesium sulfate. When the nurse is reinforcing information about the medication, which statement would be most appropriate? "You may feel flushing with a dry mouth." "You'll probably feel no different than if you had taken acetaminophen." "This medicine will make you feel hyperactive and jittery." "This medicine will help you breathe a whole lot better."

"You may feel flushing with a dry mouth."

A parent is preparing for the imminent death of a child due to sickle cell anemia. The parent has been unable to eat or sleep and talks only about the impending loss and feelings of guilt for the child's pain and suffering. Which nursing intervention has the highest priority? Help the parent to understand the phases of the grieving process. Reassure the parent that the child's death is not the parent's fault. Arrange for genetic counseling for the parent to determine risk of the disease. Allow the parent to express feelings without judgement.

Allow the parent to express feelings without judgement.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? Bring a small glass of juice, and locate the client. Send the nurse's assistant to the x-ray department to bring the client back to the room. Check the computerized care plan to determine what test was scheduled. Call the client's health care provider (HCP).

Check the computerized care plan to determine what test was scheduled.

A client in her second trimester tells the nurse that she feels very anxious because she is not sure of what will happen when she goes into labor to give birth. Which intervention by the nurse would be most appropriate for this client? Provide her and her partner with written information about the birthing process. Arrange for a more experienced pregnant woman to assist her. Help her enroll in birth preparation classes at the facility where she plans to give birth. Tell her that she will learn to cope as her pregnancy progresses.

Help her enroll in birth preparation classes at the facility where she plans to give birth.

A licensed practical nurse (LPN) who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short-staffed. The nurse has never worked in a CCU. Which action by the nurse would be most appropriate? Speak to the nursing supervisor about the request for the nurse to go to the CCU. Refuse to go to the CCU due to lack of experience. Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU. Call the hospital risk manager to report the request as a violation.

Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU.

A nurse is preparing to assist a client who underwent gastroplasty yesterday to ambulate. The client has an IV line in place, a nasogastric (NG) tube connected to suction, and oxygen running at 6 L/minute by way of a nasal cannula. The health care provider has ordered patient-controlled analgesia (PCA) with morphine sulfate. What is the best way to plan for this client's walking activity? Wait until a physical therapist is available. Ask the client to withhold the PCA for 45 minutes before the walk to prevent orthostatic hypotension. Connect the NG tube to a portable suction machine while the client is walking. Obtain a portable oxygen tank to maintain oxygen delivery during the client's ambulation.

Obtain a portable oxygen tank to maintain oxygen delivery during the client's ambulation.

A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best? Explaining to the client that he can't have anything by mouth until after testing. Performing mouth care Offering the client ice chips Increasing the infusion rate of the client's I.V. fluids.

Performing mouth care

A nurse is caring for an older adult client who is confused. Which nursing intervention can best help to prevent this client from falling? Restrain the client to reduce the possibility of getting out of bed and falling. Place the client in an area where regular or continual monitoring is possible. Keep the bed at a level so that care can be provided easily by the staff.. Lower the side rails of the bed to prevent the client from climbing over them.

Place the client in an area where regular or continual monitoring is possible.

What should the nurse do with linens that have been soiled by a client with hepatitis? Place them on the floor until the laundry department can pick them up. Place them in a plastic bag that has a contamination symbol. Place them in the dirty linen receptacle. Place them in a hazardous waste receptacle.

Place them in a plastic bag that has a contamination symbol.

A client with type 1 diabetes in the second trimester of pregnancy is hospitalized for diabetes management. She performs blood glucose testing at 6 a.m., 11 a.m., 4 p.m., and 9 p.m. At 8 a.m., the client receives NPH and regular insulin subcutaneously. At 4 p.m., the client obtains a blood glucose reading of 45 mg/dL and notifies the nurse. What should the nurse's first action be? Provide the client with a glass of skim milk. No nursing action is warranted at this time. Notify the health care provider immediately. Administer the prescribed dose of insulin.

Provide the client with a glass of skim milk.

A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP? Clean the dentures over the sink with the drain closed. Put a washcloth in the sink to prevent damage the dentures. Scrub the dentures with a cleaning agent and cold water. Rinse the dentures under hot running water.

Put a washcloth in the sink to prevent damage the dentures.

The licensed practical nurse ( LPN) is working with a registered nurse (RN) and a nursing assistant (NA) utilizing the team nursing concept. When discussing client assignment, which clients should be assigned to the LPN? Select all that apply. a 4-year-old returning from the operating room following a tonsillectomy who is crying, stating pain, and asking for a parent. a client with history of diabetes and requires QID blood glucose readings and insulin administration with sliding scale coverage. A client needing an intravenous line discontinued and then is ready for discharged a 56-year-old client with sternal pain radiating to the right shoulder and jaw. an adult client with knee abrasions and a sprained ankle who is requesting pain medication and is learning to use crutches A client with pneumonia who is receiving breathing treatments and IV antibiotics

a client with history of diabetes and requires QID blood glucose readings and insulin administration with sliding scale coverage. an adult client with knee abrasions and a sprained ankle who is requesting pain medication and is learning to use crutches A client with pneumonia who is receiving breathing treatments and IV antibiotics A client needing an intravenous line discontinued and then is ready for discharged

A nurse is caring for a client who practices the Mormon faith. Which nursing actions would be most helpful in meeting the client's spiritual needs? Select all that apply. offering to contact a clergy member to provide support to the client supporting the client's decision not to accept blood transfusions allowing the client to wear a special undergarment, even during hygiene procedures providing tea with meals

offering to contact a clergy member to provide support to the client