312- Foundations of Nursing Exam 2

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?

"I will need to check with your health care provider about that." NOT- "No—you should stay on your normal medication schedule before the surgery."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns NOT- Readiness for Enhanced Nutrition related to constipation

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance NOT: Asthma Attack

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. NOT- Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat.

While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?

Islam NOT- Judaism

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?

Risk for falls NOT: hypertension

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?

Updating the diet orders in the client's plan of care

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is:

a guideline.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:

a partial airway obstruction. NOT- the effects of anesthesia.

The nurse knows the term perioperative phase refers to care given to the client:

before, during, and after the operative phase. NOT- immediately before an operative procedure.

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:

developing shock. NOT- allergic to the anesthesia.

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. The nurse informs the parents that the development of a child's spirituality is best accomplished by:

educating through parental behaviors. NOT- educating the child about religion.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?

emergency surgery

A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for:

hemorrhage.

One major requirement of a nursing diagnosis is that it focus on a problem that is:

legally treatable by registered nurses. NOT- based on the client's pathophysiology.

A client will be having a surgical procedure requiring general anesthesia. Which desired outcomes of general anesthesia does the nurse expect to observe? Select all that apply.

loss of consciousness analgesia relaxed skeletal muscles depressed reflexes NOT- loss of sensation in specific area

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect?

paralytic ileus NOT- normal response

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease?

slow wound healing

He tells a nurse that there is no God that he knows of who would subject someone to this. The client's statement is most reflective of:

spiritual crisis. NOT- separation from spiritual ties.

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?

"I can have a hamburger and French fries as soon as I wake up." NOT- "The better I eat before surgery, the more likely I will heal."

When asked about his religious preference, the client becomes very upset with the nurse. Which response is appropriate for this situation?

"I can see that this question upsets you. Do you have any questions about this?" NOT- "I can see that this upsets you. Let me come back later when you are feeling better."

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

A registered nurse (RN) is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate for the RN to delegate to the LPN/LVN? Select all that apply.

Administer oral aspirin and lisinopril to the client with hypertension Insert a nasogastric tube in a client with absent bowel sounds Reinforce a postsurgical abdominal dressing

The nurse admits a client to the critical care unit to rule out a myocardial infarction. The client has several family members in the waiting room. Which nursing action is most appropriate?

Assess the client's beliefs about family support during hospitalization. NOT- Allow all the visitors into the room.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible. NOT- Perform all care activities for the client to facilitate rest.

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority?

Measure respiratory rate.

The nurse is caring for a dying male client who practices Islam. What is the most appropriate action for the nurse after the client's death?

Ensure that a male washes the client's body.

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

Include the client and the client's power of attorney in the discussion.

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Record the client's intake and output. Assist the client to the bedside commode. NOT- Administer routine oral medications.

The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met. NOT- Contact the lactation consultant and ask if the plan of care needs to be modified.

A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education?

The client demonstrates administration of insulin. NOT- The client identifies correct insulin injection sites.

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

dehiscence

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change.

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

The client tells the nurse about following the holistic belief of hot/cold. Which food items should the nurse provide to the client based on this information?

Soup, hot tea, and toast

A physical examination on a client should always include which components? Select all that apply.

Appraisal of health status Identification of health problems Establishment of a database for interventions

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal?

As soon as possible

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure.

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid?

Aspiration NOT: Bowel alterations

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain.

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety?

Assist the client to identify strategies to promote safety in the home. NOT- Instruct the client about the need to keep the walkway to the bathroom clear.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt.

Which behavior by the nurse is stereotyping?

Avoiding older adult clients because their care is time consuming

Which are benefits of using the nursing intervention classification (NIC) system for the development of interventions? Select all that apply.

Creation of a standardized language Assistance in determining the cost of services that nurses provide Demonstration of the impact of nurses

Which surgical clients will return to activities in their everyday lives more quickly? - Vaginal hysterectomy - Laparoscopic cholecystectomy - Open-heart surgery - Right nephrectomy

Laparoscopic cholecystectomy - this removes your gallbladder

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Monitor the client closely and promote fluid intake. NOT- Contact the physician to come assess the client.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight. NOT: Immediately have the client sign the consent form.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant NOT- A senior nursing student present for clinical

"Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

Which nursing skill uses all five senses?

Observation NOT- Documentation

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital NOT: Once the client has received a discharge order

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase

Which nursing action will best promote pain management for a client in the postoperative phase?

Performing relaxation techniques NOT- Providing food and medication

. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?

Physical changes

A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?

Potential for hypothermia or hyperthermia NOT- Gastrointestinal upset

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

Presence of peristalsis --> DIGESTION SOUNDS

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed?

Prolonged Immobility related to impaired skin integrity NOT- Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique. NOT: Cover the infant.

During data collection the nurse may validate data by which method? Select all that apply.

Referring to textbooks, journals, and research reports Checking the consistency of cues Clarifying the client's statements Seeking consensus among colleagues about inferences

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements?

Religion is a collection of spiritual beliefs and practices.

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

"I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

The nurse is assessing a client in an outpatient setting. The client states,"I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client?

Risk for Suicide NOT: Impaired Gas Exchange

Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation?

Separation from spiritual ties

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure

The nurse recognizes that palliative surgery is performed for what purpose?

to lessen the intensity of an illness

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?

"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." NOT- "An advance directive is a living will. Some people already have one when they come to the hospital."

Which question would be appropriate for the F in the FICA spiritual assessment tool?

"Do you consider yourself a spiritual person?"

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this." NOT: "Why are you treating me this way?"

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?" NOT: "Do you have any additional questions for me?"

A nurse is having problems communicating with a client. Which statement by the nurse would open up the most dialogue with the client?

"You are back from therapy; tell me about it."

Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications?

76-year-old client with a history of renal failure and chronic bronchitis NOT- THE 6 MONTH OLD

unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

The client outcome, "The mother will express confidence in being able to meet nutritional needs of the infant," is an example of which type of outcome statement?

Affective NOT- Cognitive

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

Which activity is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering captopril

The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?

Client will maintain nutritional intake without pain or diarrhea. NOT- Client will learn to cook foods that meet personal nutritional needs.

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem NOT: Interdisciplinary health problem

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

Which term describes the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture?

Cultural imposition

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse?

Discuss with the client the need for assistance during ambulation. NOT: Obtain a prescription for physical therapy consult to ambulate the client.

The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response?

Document the client's request in the nursing care plan. NOT: Explain to the client that the client is required to make all decisions related to the client's own health care.

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached?

Empathy NOT: Sympathy

The nurse is caring for Mr. Z., a 55-year-old man admitted to the hospital for liver failure. He is an active member in the Latter-Day Saints (Mormon) church. Mr. Z. tells the nurse that he strictly adheres to the religious practices that are condoned by the church. However, the nurse overhears two of his physicians discussing that Mr. Z.'s liver failure is likely due to chronic alcohol use. The nurse suspects that they are wrong. Which of the following is an appropriate nursing activity?

Engage Mr. Z. in a discussion about past and present religious practices. NOT- Order several laboratory tests looking for genetic defects that affect the liver.

The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure NOT- Providing medication for agitation

A subculture may be based on which characteristics? Select all that apply.

Gender Age Profession Hobbies Sexual preference

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process?

Evaluation

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase?

Examine goals of the relationship to determine whether they were achieved

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client NOT- Feedback from the family

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply.

Imbalanced nutrition Ineffective coping Impaired mobility

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?

Ineffective Impulse Control NOT- Agitated Movement

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response?

Inform the anesthesiologist or surgeon of this fact.

The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?

Instruct the student to provide the client with a pillow or folded blanket to hug.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply.

Spoken words Sight Touch Observation

A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with the client in a one-bedroom apartment. Which consideration is the priority nursing concern?

The client does not have running water.

Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and **why** the client needs to check the blood glucose level. NOT: The client can demonstrate the correct technique for using a new glucometer.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me." NOT: The client makes funeral plans.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease.

A nurse is evaluating nursing care and client outcomes by using a **retrospective evaluation**. Which action would the nurse perform in this approach?

The nurse devises a postdischarge questionnaire to evaluate client satisfaction.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?

a woman who takes daily anticoagulants to treat atrial fibrillation

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet. NOT- partially met.

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality. NOT: review literature pertinent to the client's attributes.