317 Exam 1 Review Questions
A
. Who or what is the primary source of information for a nursing history? a) The client b) Other health care personnel c) Previous medical records d) Family members
D
A 68-year-old client in the hospital with a chronic illness is 25% overweight. This client refuses to eat vegetables and continues to ask for food to be delivered from the local pizza restaurant. Which of the following might this client be experiencing? a. Protein-calorie malnutrition b. Undernutrition c. Overnutrition d. Both over and undernutrition
D
A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown? a) Keep the client in a semi-Fowler's or high-Fowler's position. b) Ensure the client is adequately hydrated. c) Massage or stimulate the client's skin surfaces daily. d) Reposition the client on a regular basis.
C
A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a) keeping an accurate medication record b) notifying the nursing team of the client's condition c) accurately documenting client care on the client record d) documenting client data on the flow sheet
ADE
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. a) Nasal cannula b) Venturi mask c) Humidified venturi mask d) Partial rebreather mask e) Simple oxygen mask
A
A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate? a) "Performing Kegel exercises can help with muscle strengthening." b) "You need to decrease your daily fluid intake to help with this." c) "Coffee and diet sodas are not factors with being incontinent of urine." d) "It is best to have a Foley catheter inserted to prevent incontinence."
B
A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to: a) take a cough suppressant to decrease coughing. b) increase her fluid intake to thin secretions. c) decrease exercise and increase rest periods. d) eat small, frequent meals to conserve energy.
B
A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? a) "I will tell the doctor you are having problems; maybe he can help." b) "When you increase fiber in your diet, you also need to increase liquids." c) "Just give it a few more days and you should be fine." d) "Well, that shouldn't happen. Let me recommend a good laxative for you."
B
A client who is undernourished is seen in the clinic for an infected foot wound. The nurse realizes this client is at continued risk for: a. Elevated iron level b. Ongoing infections c. Elevated albumin level d. The development of type 2 diabetes
A
A full-thickness burn develops a leathery covering called a(an): a) eschar. b) static. c) abrasion. d) erythema.
D
A home care nurse is visiting a client as a part of a regular visit. The client's daughter age 4 years falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect? a) Resolution of inflammation b) Increased blood flow c) Relief of muscle stiffness d) Help in controlling swelling
A
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall with a pillow
A
A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? a) white blood cells, debris, bacteria b) clear, watery blood c) mixture of serum and red blood cells d) large numbers of red blood cells
A
A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: a) primary intention. b) secondary intention. c) tertiary intention. d) dehiscence.
D
A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition
A
A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority? a) Evacuate the client. b) Confine the fire. c) Raise an alarm. d) Extinguish the fire.
C
A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is: a) "You will need to sit up for your bath, and then I will change your bed." b) "I really have limited time. Let me give you your bath right now." c) "I will set up your bath for you. I will come back and help you with your bath." d) "You will be able to take your bath by yourself tomorrow when you can get up."
C
A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition? a) Fecal incontinence b) Secondary constipation c) Fecal impaction d) Iatrogenic constipation
D
A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? a) Anuria b) Oliguria c) Polyuria d) Dysuria
B
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on the QSEN competency of safety? a) The nurse keeps visitors 3 feet away from the infected person. b) The nurse places the client in a private room with monitored negative air pressure. c) The nurse uses droplet precautions when providing care for the client. d) The nurse places the client in a private room with the door open.
B
A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer? a) 35-year-old client who was admitted after a motor vehicle accident and has bilateral casts b) 65-year-old incontinent client with a hip fracture on bed rest c) 45-year-old client who has cancer, is receiving chemotherapy, and being admitted with leukopenia d) 70-year-old client with Alzheimer's who wanders the nursing unit and refuses to sit and eat meals
D
A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? a) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. b) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence. c) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. d) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.
A
A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? A. Cut in the skin from a kitchen knife B. Excoriated perineal area C. Abrasion of the skin D. Pressure ulcer
B
A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a) Use clean technique to clean the wound. b) Clean the wound from the top to the bottom, and center to outside. c) Once the wound is cleaned, dry the area with an absorbent cloth. d) Clean the wound from the bottom to the top, and outside to center.
A
A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. What would be most appropriate to include? a) "Clear the clutter from the stairways and walkways." b) "Keep all medications within the client's reach." c) "Get the client immunized against whooping cough." d) "Avoid the use of nightlights in the client's bedroom."
C
A nurse is promoting exercise and activities for an elderly patient. Which teaching point would be appropriate for this patient? a) Encourage the patient to quickly increase the repetitions for arm and leg exercises. b) Teach the patient to force joints to meet their natural limit and beyond prior to modifying exercises. c) Encourage the patient to warm up before beginning exercises and to cool down after exercising. d) Instruct the patient to continue exercise even if feeling weakness, to build up stamina.
C
A nurse is providing oral care to a client with dentures. What action would the nurse perform first? a) Wash the client's face. b) Apply lubricant. c) Don gloves. d) Assess the mouth and gums.
D
A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place? A. Assessment B. Planning C. Implementation D. Evaluation
B
A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? a) The nurse performs routine care and is moving to another patient. b) The nurse is caring for a client with a C. difficile infection. c) The nurse finishes patient care and hands are not visibly soiled. d) The nurse finishes cleaning a patient's table.
B
A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room? a) removing personal protective equipment that is most contaminated first b) thorough handwashing c) spraying of disinfectant d) placing one bag of contaminated items within another
D
A nursing student is conducting an interview with a client. Which of the following best demonstrates use of open-ended questions in an interview? a) Do you participate in any illicit drugs? b) Are you feeling well? c) Do you smoke? d) How are you feeling?
D
A patient is taking delayed-release omeprazole (Prilosec) capsules for the treatment of gastroesophageal reflux disease (GERD). Which statement will the nurse include in the teaching plan about this medication? A. "Take this medication once a day after breakfast." B. "You will only have to be on this medication for 2 weeks for a life long treatment of the reflux disease." C. "The medication may be dissolved in a liquid for better absorption." D. The entire capsule should be taken whole, not crushed, chewed or opened.
BCDE
A school nurse is teaching a group of adolescents about safe driving. What behaviors should the nurse encourage in order to help prevent motor vehicle accidents? (Select all that apply.) a) Drive at night when fewer people are on the road. b) Obey the speed limit. c) Never text while driving. d) Always wear a seat belt. e) Limit the number of other adolescents in the car.
B
A staff development nurse is discussing techniques to prevent back injury with a group of unlicensed assistive personnel (UAP). The nurse informs the group that back stress and injury can be prevented by: a) holding the object that you are lifting/moving away from the body. b) spreading the feet shoulder-width apart to broaden the base of support. c) using the strength of the back muscles during strenuous activities. d) pulling equipment, rather than pushing it, when possible.
D
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? a) An infectious agent b) A portal of exit c) A portal of entry d) A reservoir
A
A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which condition is likely affecting the client? a) Orthostatic hypotension b) Thrombophlebitis c) Anemia d) Bradycardia
D
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed? a) To the dominant side of the client, with legs together and one foot near the head of the bed b) Near the client's hip, with legs together c) To the nondominant side of the client, with legs together and one foot near the head of the bed. d) Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed
C
After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat? a) Cream of wheat, cranberry juice, and milk b) Fat-free broth, ginger ale, and custard c) Bouillon, apple juice, and gelatin d) Clear broth, hot tea, and yogurt
D
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the student have understood the material when they identify which of the following as a cause of stress incontinence? a. Obstruction due to fecal impaction or enlarged prostate b. Bladder irritation related to urinary tract infections c. Increased urine production due to metabolic conditions d. Decreased pelvic muscle tone due to multiple pregnancies
A
An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin? a) activity of the glands in the skin lessens b) the symptoms are indicators of a disease c) skin gland activity increases, leading to acne d) the symptoms are unrelated to aging skin
A
At what age is peak bone density achieved in women? A. Age 20 B. Age 18 C. It depends on factors like nutrition and activity levels. D. age 40
A
Dehiscence is the softening of tissue due to excessive moisture. a) False b) True
D
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Humidifier b) Nasal cannula c) Oxygen analyzer d) Flow meter
C
Full thickness skin loss involving damage or necrosis of subcutaneous tissue A. Stage I B. Stage II C. Stage III D. Stage IV
B
In what situation would the use of side rails not be considered a restraint? a) The institution's policies mandate using side rails. b) A client requests they be up at night. c) The nurse keeps them raised at all times. d) A visitor requests their use.
A
Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site C. Debriding the ulcer to remove necrotic tissue, which can impede healing D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated
C
It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation? A. A 16-year-old with a sprained ankle being discharged from the emergency department B. A 54-year-old who has taken the initial dose of an antihypertensive medication C. A 45-year-old postoperative client up for the first time since knee surgery D. An 81-year-old who is asthmatic and had a hip replaced 18 months ago
B
Montgomery straps allow the nurse to change a dressing without the use of tape. a) False b) True
A
Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls? a) Lock wheels on beds and wheelchairs. b) Keep bed in the high position. c) Keep side rails up at all times. d) Apply restraints to all confused clients.
D
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's bestaction? a) Consult with the physical therapist to determine the client's ability. b) Instruct the client's family to assist the client to ambulate to the bathroom. c) Continue assisting the client to the bathroom to ensure the client's safety. d) Revise the care plan to allow the client to ambulate to the bathroom independently.
A
Of all factors, what is the most important risk factor in pulmonary disease? a) active and passive cigarette smoke b) loss of the ozone layer of the atmosphere c) dangerous chemicals in the workplace d) air pollution from vehicles
D
Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? A. Poor client compliance resulting from generalized diminished capacity B. Inadequate health insurance coverage for the group as a whole C. Insufficient research to provide a basis for effective geriatric health care D. Preconceived assumptions regarding the lifestyles and attitudes of this group
B
Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called which of the following? a) Evidence-based practice b) Evaluative statement c) Standard d) Criteria
A
Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy? a) raising all side rails while the client is in bed b) raising one bed rail to offer stabilization when standing c) placing the client in a bed with a bed alarm d) providing a bed that is low to the floor
D
Oxygen and carbon dioxide move between the alveoli and the blood by: a) hyperosmolar pressure. b) negative pressure. c) osmosis. d) diffusion.
B
The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? a) low blood pressure b) high respiratory rate c) low pulse rate d) high temperature
D
Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education? a) "I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper." b) "At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night." c) "I've made a point of scheduling when I drink water instead of waiting until I'm thirsty." d) "I make sure to limit how much I drink so that I don't have accidents."
B
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is mostappropriate? a) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b) "Your wound will heal slowly as granulation tissue forms and fills the wound." c) "As soon as the infection clears, your surgeon will staple the wound closed." d) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."
B
The care plan for a client who has been frequently admitted to the hospital for exacerbation of COPD (chronic obstructive pulmonary disease) has a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis? a) Assess the severity of the client's illness. b) Assess the client's knowledge of COPD. c) Assess the client's financial resources. d) Assess the client's access to health care.
B
The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abdominal assessment C. Administer an anti-nausea medication D. Notify the physician
D
The leading cause of injury and preventable source of mortality and morbidity in older adults is A. presbycusis. B. car accidents. C. pneumonia. D. falls.
D
The mother of a 2-year-old child tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother? a) "You really like to keep your child clean. Good for you!" b) "Show me exactly how you use the hairpin." c) "That's not good. Use a Q-tip or your finger instead." d) "That is dangerous; you might puncture the eardrum."
B
The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? a) "What are your plans after discharge?" b) "Please tell me your thoughts about treating this diagnosis." c) "You need to stop smoking for us to effectively combat this disease." d) "Do you want to be discharged without treatment?"
B
The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis? a) Client's report of researching treatment options for melanoma b) Client's report of increased consumption of alcohol c) Client's report of eating more fruits and vegetables d) Client's report of reading the Bible and praying daily
D
The nurse defines ageism most accurately as: A. The undervaluing of individuals based on their age. B. Perception of a person's worth based on productivity C. Biases directed towards individuals considered aged D. Discrimination based on an individual's increasing age
C
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene? a) Do not wash hands; apply clean gloves. b) Wash hands with soap and hot water. c) Decontaminate hands using an alcohol-based hand rub. d) Wash hands with soap and water, followed by an alcohol-based hand rub.
B
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? a) Reduce the frequency of meals in order to allow the client to develop an appetite. b) Try to ensure that the client's food is attractive and sufficiently warm. c) Offer larger meals and encourage the client to eat as much as is comfortable. d) Offer nutritional supplements and explain the potential benefits of each.
B
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessing B. Diagnosing C. Planning D. Evaluating
C
The nurse instructs the family of an older adult client with a visual impairment and decreased mobility that the most common problem for these clients is related to: a) electrical cords b) medication errors c) falls d) aspiration
B
The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which of the following actions by the nurse is appropriate? a) Question the need for the examination because the client must remain in Airborne Precautions. b) Place a surgical mask on the client and transport to the CT department at the specified time. c) Notify the CT department in advance so other clients and staff can be removed from the area. d) Request that the examination be done at the bedside.
C
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown? a) Before taking the client's pulse b) After entering the client's room c) Before entering the client's room d) After taking the client's pulse
C
The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action? a) Tell the client that the physician has ordered sleep medication if necessary. b) Determine if the nurses have time to give the client's bath at night. c) Reschedule the client's bath to the evening shift. d) Ask the client for permission to give the bath in the morning.
D
The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: A. Diagnose if the patient is at risk for falls. B. Ensure that the patient's skin is intact C. Establish a therapeutic relationship D. Identify important data
B
The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective? a) Revising the facility's infection control protocols b) Incentivizing health care workers to utilize hand hygiene c) Limiting visitors to family members over the age of 18 d) Encouraging visitors to adhere to isolation precautions
B
The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility? A. "Your shoulder pain is normal for your age." B. "Continue to exercise your joints regularly to your tolerance level." C. "Why don't you begin walking 3 to 4 miles a day, and we'll evaluate how you feel next week." D. "Don't worry about taking that combination of medications since your doctor has prescribed them."
B
The nurse would recognize which client as being particularly susceptible to impaired wound healing? a) a client whose breast reconstruction surgery required numerous incisions b) an obese woman with a history of type 1 diabetes c) A client who is n.p.o. (nothing by mouth) following bowel surgery d) a man with a sedentary lifestyle and a long history of cigarette smoking
D
The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults: A. Require institutional care B. Have no social or family support C. Are unable to afford any medical treatment D. Are capable of taking charge of their own lives
B
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene? a) The nurse uses hand hygiene instead of gloves when in contact with blood. b) The nurse keeps fingernails less than ¼ inch long. c) The nurse refrains from using hand moisturizer following hand hygiene. d) The nurse uses gloves in place of hand hygiene.
A
The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response? a) "You are free to move onto the stretcher without assistance, but I will supervise for your safety." b) "You cannot transfer without my help because you need a friction-reducing device to prevent harm to your skin." c) "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." d) "I can only allow you to transfer without assistance based upon a physician's order, so I will now help you."
B
The proper use of the principles of body mechanics: a) acts as a safeguard against legal action by the client. b) acts to prevent injury to the client and/or nurse. c) primarily protects the client from injury. d) Primarily protects the nurse from injury.
C
There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age: A. Men have the greatest incidence of osteoporosis B. Muscle fibers increase in size and become tighter C. Weight-bearing exercise reduces the loss of bone mass D. Muscle strength does not diminish as much as muscle mass
C
While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound? a) Stage IV pressure ulcer b) Stage III pressure ulcer c) Stage II pressure ulcer d) Stage I pressure ulcer
A
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging
D
While performing passive range-of-motion exercises on the lower extremities of a client with a spinal cord injury, the nurse assesses permanent flexion of the muscles. What term will the nurse use to document this finding related to the muscles? a) Atrophy b) Tonus c) Ankylosis d) Contractures
D
What does pulse oximetry measure? a) Peripheral blood flow b) Venous oxygen saturation c) Cardiac output d) Arterial oxygen saturation
D
What is the route of administration for TPN? a) Intramuscular b) Subcutaneous c) Oral d) Intravenous
A
What types of dressings are most recommended for pressure ulcers? A. Gauze B. Transparent C. Hydrocolloid D. None
C
When a fall results in injury and hospitalization, a cycle of disuse may occur over time. When establishing a care plan for the patient and family to prevent this, it is important to remember disuse is most likely a result of: A. Decreasing muscle strength. B. Decreased joint mobility. C. Fear of repeated falls. D. Changes in sensory perception
C
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? a) Surveillance b) Maintenance c) Psychomotor d) Psychosocial
B
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? a) Airborne b) Contact c) Vehicle d) Vector
A
When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Off-load pressure from the heel. b) Contact the surgeon for deibridement. c) Place a TED hose on the client's leg. d) Using sterile technique, debride the wound.
B
When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about? A. Post surgical hemorrhage and anemia B. Wound dehiscence and evisceration C. Impaired skin integrity and decubitus ulcers D. Loss of motility and paralytic illeus
D
When providing oral care, what does the nurse recognize as the most important component of the oral care process? a) application of moisturizing ointment to the lips b) selection of toothpaste c) use of a mouthwash or breath freshener d) a thorough, mechanical cleaning
A
When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging? A. thinning of the epidermis B. thickening of the epidermis C. oiliness of the skin D. increased elasticity of the skin
C
Which client would be most at risk for alterations in oral health? a) Healthy young adult b) Woman who is pregnant c) Man with a nasogastric tube d) Infant who is breast-fed
B
Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes
A
Which is one of the most important benefits of a nurse helping with bathing? a) Nurse-client relationships are facilitated. b) The nurse improves technical skills. c) Staff-nurse relationships are more collegial. d) The client sees professional staff.
C
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? A Ibuprofen (Motrin) B Celecoxib (Celebrex) C Aspirin (Ecotrin) D Indomethacin (Indocin)
D
Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated
A
While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? a) Periodontitis b) Halitosis c) Caries d) Plaque