ch6=8,18,19

The nurse provides client education regarding hypertension prevention and management. Which statement indicates that the client understands the instructions? 1) "I don't have to worry if my blood pressure is high once in a while." 2) "I guess I will have to make sure I don't drink too much water." 3) "I can lose some weight to help lower my blood pressure." 4) "I will need to reduce the amount of milk and other dairy products I consume."

"I can lose some weight to help lower my blood pressure."

The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? 1) "I would have the client rate her pain on a scale of 0 to 10." 2) "I would ask the client when she had her last bowel movement." 3) "I would take the client's pulse oximetry reading." 4) "I would interview the client about history of tobacco use."

"I would have the client rate her pain on a scale of 0 to 10."

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? 1) "Occurrence reports track problems and identify areas for quality improvement." 2) "Occurrence reports are required by the Food and Drug Administration to report drug errors." 3) "The Joint Commission requires occurrence reports for all client falls." 4) "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

"Occurrence reports track problems and identify areas for quality improvement."

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include? 1) "Be sure to put mittens on the baby." 2) "Layer the infant's clothing." 3) "Place a cap on the infant's head." 4) "Put warm booties on the baby."

"Place a cap on the infant's head."

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? 1) "Record how much the patient drinks today, please." 2) "Take the patient's vital signs every 2 hours today." 3) "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." 4) "Assist the patient with all of her meals."

"Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." What would be the nurse's best response? 1) "Your vital signs confirm that your infection is resolved; how do you feel?" 2) "I'll let your healthcare provider know so you can be discharged." 3) "Your vital signs are stable, but there are other things to assess." 4) "We still need to keep monitoring your temperature for a while."

"Your vital signs are stable, but there are other things to assess."

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1) "I can wait until the end of the shift to document my care." 2) "I can wait until the end of the shift to document my care." 3) "I find it easier to chart before I go to lunch and then after my shift report." 4) "I should chart as soon as possible after nursing care is given." 5) "I document medications given before providing them to the patient."

1) "I can wait until the end of the shift to document my care." 2) "Charting every 2 hours is the most appropriate way to document nursing care." 3) "I find it easier to chart before I go to lunch and then after my shift report." 5) "I document medications given before providing them to the patient."

Which statement by the student nurse indicates an understanding of the nursing Kardex®? Select all that apply. 1) "The Kardex® pulls data from multiple areas of the patient's chart." 2) "The Kardex® is usually kept at the patient's bedside." 3) "The Kardex® is used to document patient response to interventions." 4) "The Kardex® summarizes the plan of care and guides nursing care." 5) "The Kardex® is a portable file of patient information."

1) "The Kardex® pulls data from multiple areas of the patient's chart." 4) "The Kardex® summarizes the plan of care and guides nursing care." 5) "The Kardex® is a portable file of patient information."

The nurse and nursing assistive personnel (NAP) are caring for a group of clients on the medical-surgical floor. For which client can the nurse delegate to the NAP the task of bathing? Select all that apply. 1) 75-year-old client newly admitted to the hospital with dehydration 2) 65-year-old client hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old client with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old client with chronic renal failure who has vital signs within his normal range 5) 45-year-old client recovering from arthroscopic knee surgery

1) 75-year-old client newly admitted to the hospital with dehydration 3) 92-year-old client with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old client with chronic renal failure who has vital signs within his normal range 5) 45-year-old client recovering from arthroscopic knee surger

The nurse prepares to evaluate the status of collaborative problems. What action should the nurse take during this evaluation? Select all that apply. 1) Compare data with established norms. 2) Study the goals on the client's care plan. 3) Report a worsening condition to the healthcare provider. 4) Mark an outcome successful if no complication occurred. 5) Designate a problem as resolved when data are within normal limits.

1) Compare data with established norms 3) Report a worsening condition to the healthcare provider. 4) Mark an outcome successful if no complication occurred.

Before conducting research on a group of clients, the nurse makes an appointment with the Institutional Review Board (IRB). Why did the nurse perform this action? 1) Ensure that the research is of value 2) Review the method to ensure confidentiality 3) Validate whom the subjects should contact with questions 4) Approve the statement that subjects can stop participating at any time

1) Ensure that the research is of value

What should the nurse understand as being advantages of an electronic health record (EHR)? Select all that apply. 1) Facilitate evidence-based nursing practice 2) Promote efficient use of the nurse's documentation time 3) Reduce the opportunity for interdisciplinary collaboration 4) Ensure improved client safety and outcomes 5) Reduce cost for documenting care electronically

1) Facilitate evidence-based nursing practice 2) Promote efficient use of the nurse's documentation time 4) Ensure improved client safety and outcomes

Which findings are specific indicators of hypoxia? Select all that apply. 1) Feelings of anxiety 2) Crackles in the lung bases 3) Increased heart rate 4) Improved breathing in upright position 5) Cyanosis of the tongue

1) Feelings of anxiety 3) Increased heart rate 5) Cyanosis of the tongue

The nurse manager provides the staff with a research article about different types of products used for wound care. What needs to be present to determine whether a nursing theory was used for this study? Select all that apply. 1) Health 2) Person 3) Nursing 4) Paradigm 5) Environment

1) Health 2) Person 3) Nursing 5) Environment

Which action by the nurse breaches patient confidentiality? Select all that apply. 1) Leaving patient data displayed on a computer screen where others are able to view them 2) Remaining logged on to the computer system after documenting patient care 3) Faxing a patient report to the nurses' station at the facility where the patient is being transferred 4) Informing the nurse manager of a change in the patient's condition 5) Reviewing the medical record of a next-door neighbor admitted for a health problem

1) Leaving patient data displayed on a computer screen where others are able to view them 2) Remaining logged on to the computer system after documenting patient care 5) Reviewing the medical record of a next-door neighbor admitted for a health problem

Which actions should the nurse take to increase the use of evidence-based practice when providing client care? Select all that apply. 1) Participate in research studies 2) Share research findings with peers 3) Use research findings to guide practice 4) Volunteer to serve as a member of a research study 5) Incorporate research findings when changing practice

1) Participate in research studies 2) Share research findings with peers 3) Use research findings to guide practice 5 Incorporate research findings when changing practice

The nurse determines that a client's care plan needs to be revised. What parts of the current care plan will the nurse review prior to making revisions? Select all that apply. 1) Teaching 2) Diagnosis 3) Outcomes 4) Assessment 5) Medications

1) Teaching 2) Diagnosis 3) Outcomes 4) Assessment

When performing a hand-off report, the nurse should communicate information on which aspect of care? Select all that apply. 1) Teaching performed 2) Any change in client status 3) Treatments administered 4) Hygiene measures performed 5) Routine care provided

1) Teaching performed 2) Any change in client status 3) Treatments administered

A client's vital signs at the beginning of the shift are oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the client's oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min? 1) 62 2) 82 3) 102 4) 122

102

At 1000 on 11/14/17, the nurse receives a telephone order for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? 1) 11/14/17 at 1200 2) 11/14/17 at 2200 3) 11/15/17 at 1000 4) 11/16/17 at 1000

11/15/17 at 1000

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1) 14 days 2) 3 days 3) 2 days 4) 24 hours

14 days

A client's vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, what should the nurse anticipate the client's respiratory rate to be? 1) 16 2) 18 3) 20 4) 22

18

The nurse prepares a teaching session on blood pressure for a group of nursing students. What should the nurse explain can falsely elevate the blood pressure measurement? Select all that apply. 1) Cuff that is too wide 2) Cuff that is too narrow 3) Mild to moderate pain present 4) Measuring after the client smokes 5) Measuring after a client ambulates

2) Cuff that is too narrow 3) Mild to moderate pain present 4) Measuring after the client smokes 5) Measuring after a client ambulates

The nurse plans to assess a client's developmental stage. Which theorist should the nurse use as the basis of this assessment? Select all that apply. 1) Selye 2) Gilligan 3) Erickson 4) Kohlberg 5) Bertalanffy

2) Gilligan 3) Erickson 4) Kohlberg

The nurse locates a research study that addresses a client's health problem. What characteristics should the nurse use to evaluate the quality of the evidence within the study? Select all that apply. 1) Cost 2) Impact 3) Validity 4) Applicability 5) Time efficiency

2) Impact 3) Validity 4) Applicability

The nurse prepares an in-service session on nursing theory prior to a study being conducted on the care area. Which phrase should the nurse use to explain nursing theory? Select all that apply. 1) Is a statement of a fact 2) Is based on observations of facts 3) Helps to find meaning in experiences 4) Serves to organize thinking around an idea 5) Is an organized set of related concepts and ideas

2) Is based on observations of facts 3) Helps to find meaning in experiences 4) Serves to organize thinking around an idea 5) Is an organized set of related concepts and ideas

While reviewing a study in a nursing journal, the nurse wants to identify the theory used. Which elements of a theory should the nurse identify in the document? Select all that apply. 1) Paradigm 2) Statements 3) Definitions 4) Phenomena 5) Assumptions

2) Statements 3) Definitions 4) Phenomena 5) Assumptions

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply. 1) Rhythm of the pulses 2) Strength of the pulses 3) Bilateral equality of pulses 4) Rate compared with apical pulse 5) Location of the pulse

2) Strength of the pulses 3) Bilateral equality of pulses

When measuring a blood pressure, which step is correct? Select all that apply. 1) Use a bladder that encircles 40% of the arm. 2) Wrap the cuff snugly around the client's arm. 3) Ask the client to hold the arm at heart level. 4) Have the client sit with feet flat on the floor. 5) Roll up a sleeve before applying the cuff.

2) Wrap the cuff snugly around the client's arm. 4) Have the client sit with feet flat on the floor.

The nurse receives a telephone verbal order for pain medication for a client: morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1) 09/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2) 09/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3) 09/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4) 09/02/17 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

209/02/17 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN

Which blood pressure has a pulse pressure within normal limits? Select all that apply. 1) 104/50 mm Hg 2) 120/62 mm Hg 3) 120/80 mm Hg 4) 130/86 mm Hg 5) 140/98 mm Hg

3) 120/80 mm Hg 4) 130/86 mm Hg

Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1) Blood pressure decreases less than heart rate and respiratory rate. 2) Respiratory rate remains fairly stable throughout a person's life. 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause. 5) Body temperature increases with aging.

3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause

The client's temperature is 101.1°F. Which is the correct conversion to centigrade? 1) 38.0°C 2) 38.4°C 3) 38.8°C 4) 39.2°C

38.4°C

The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist? 1) Virginia Henderson 2) Imogene Rigdon 3) Katherine Kolcaba 4) Florence Nightingale

4) Florence Nightingale

A patient returns to the medical-surgical unit after having a right hemicolectomy (abdominal surgery) for colon cancer. Which statement is an appropriate, correctly written nursing order for this patient? 1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN 2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL 3) Incentive spirometer hourly while awake 4) Offer incentive spirometer to the client—J. Smith, RN

7/12/13 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN

A client's average normal temperature is 98°F. Which temperature would be expected during the night in a healthy young adult client who does not have a fever, inflammatory process, or underlying health problems? 1) 97.2°F 2) 98.0°F 3) 98.6°F 4) 99.2°F

97.2°F

Which criterion might be used in structure evaluation? 1) Staff refrains from sharing computer password. 2) Healthcare provider washes hands with each client contact. 3) A defibrillator is accessible on each client care area. 4) Nurse verifies client identification before initiating care.

A defibrillator is accessible on each client care area.

Which set of vital signs is within normal limits for a client at rest? 1) Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54 2) Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68 3) Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84 4) Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68

The nurse refers to the Omaha System when identifying interventions. For which client population is the nurse providing care? 1) Pediatrics 2) Maternity 3) Home care 4) Aggregates

Aggregates

The nurse locates a research study that addresses a particular client care problem. What should the nurse do first before implementing the suggestions in the article? 1) Apply nursing expertise. 2) Ask the manager for permission. 3) Discuss findings with the healthcare provider. 4) Locate an organizational policy to support the finding.

Apply nursing expertise.

Which is a disadvantage of paper health records? 1) Assist collaboration 2) Provide cautionary reminders 3) Are sometimes illegible 4) Serve as a resource

Are sometimes illegible

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1-hour PRN pain. When should the nurse administer the medication? 1) Every hour around the clock 2) Immediately after taking off the order 3) As needed, but not more than once per hour 4) 1 hour after the last administered dose

As needed, but not more than once per hour

The nurse needs to insert an indwelling urinary catheter into a client who is confused and combative. Which action should the nurse take first? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the provider that the nurse cannot perform the procedure because the client is confused.

Ask a colleague for help, because the nurse cannot safely perform the procedure alone.

The nurse is teaching a client how to use a portable blood pressure device to monitor blood pressure at home. What is the most important action for the nurse to take? 1) Ask the client to demonstrate the use of the blood pressure device. 2) Explain the importance of frequent calibration of the device. 3) Give the client a chart to record his blood pressure readings. 4) Provide written instructions of the information taught.

Ask the client to demonstrate the use of the blood pressure device.

At last measurement, the client's vital signs were: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs were: oral temperature 103.2°F (38.5°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention at this time? 1) Ask the client whether he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the client's temperature. 3) Ask the client whether he is feeling chilled. 4) Take the temperature by a different route.

Ask the client whether he has had a warm drink in the last 30 minutes.

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? 1) Performs oral care 2) Assists the patient out of bed 3) Assists the patient with bathing 4) Changes the patient's operative dressings

Assists the patient out of bed

The nurse reviews Patricia Benner's primacy of caring model for a staff presentation. Which statement should the nurse use to explain this nursing theory? 1) Caring, in nursing, focuses on cultural competence. 2) Nursing theories describe what is and what is not nursing. 3) Caring is specific and relational for each nurse-client encounter. 4) Nursing assists a person to gain independence as quickly as possible.

Caring is specific and relational for each nurse-client encounter.

Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Client 4) Nurse

Client

Which statement is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30.

Client will sit out of bed in a chair for 20 minutes three times per day.

In his later work, Maslow identified growth needs that must be met before reaching self-actualization. What do these needs include? 1) Cognitive and aesthetic needs 2) Love and belonging needs 3) Safety and security needs 4) Physiological and self-esteem needs

Cognitive and aesthetic needs

The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. What does this scenario demonstrate? 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care

Collaboration

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. Which action is the most important for the nurse at this time? 1) Compare the left pedal pulse with the right pedal pulse. 2) Count the client's respiratory rate for 1 full minute. 3) Take the blood pressure in the arm without an IV. 4) Take an oral temperature with an electronic thermometer.

Compare the left pedal pulse with the right pedal pulse.

The nurse wonders whether a dry dressing would be more beneficial for a particular type of wound instead of using the wet-to-damp approach. Which part of the PICOT process is the nurse defining? 1) Time 2) Outcome 3) Comparison 4) Intervention

Comparison

After helping a client with pain, the nurse forms a mental image of pain based on personal experience. What best describes the nurse's mental image? 1) Phenomenon 2) Concept 3) Assumption 4) Definition

Concept

The nurse is reading a research article. In which section will the nurse locate information that explains the meaning of the study? 1) Abstract 2) Purpose 3) Conclusion 4) Research design

Conclusion

A client is prescribed oral aripiprazole 10 mg daily; however, the nurse is unfamiliar with the medication and cannot find it in the hospital formulary. Which action should the nurse take? 1) Administer the medication as prescribed. 2) Hold the medication and notify the prescriber. 3) Consult with a pharmacist before administering it. 4) Ask the client's nurse for information about the medication.

Consult with a pharmacist before administering it.

Which nursing intervention is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care

Consulting

Which procedure technique has the most effect on the accuracy of an apical pulse count? 1) Counting the rate for 1 full minute 2) Exposing only the left side of the chest 3) Determining why assessment of apical pulse is indicated 4) Using your ring finger to palpate the intercostal spaces

Counting the rate for 1 full minute

The nurse reviews a client's care plan. What should the nurse keep in mind when evaluating the outcomes of care? 1) Data are collected after interventions are performed. 2) Data are collected before interventions are performed. 3) Documentation occurs after evaluation is completed. 4) Evaluation involves prioritizing implementation tasks.

Data are collected after interventions are performed.

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1) It involves a cooperative effort among various disciplines. 2) The system requires diligence in maintaining a current problem list. 3) Data may be fragmented and scattered throughout the chart. 4) It allows the nurse to provide information in an unorganized manner.

Data may be fragmented and scattered throughout the chart.

The nurse assesses a client's vital signs. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standing up 2) Decreased temperature after a period of diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rate increases

Decreased blood pressure (BP) after standing up

The nurse uses Nursing Interventions Classification (NIC) to select interventions for a client's care. Which part of the listing will the nurse analyze to understand the meaning of the label? 1) Time 2) Label 3) Activities 4) Definition

Definition

A client is admitted for control of diabetes. Which statement is an appropriate direct-care intervention for this client? 1) Consulting the diabetic nurse educator for help with a teaching plan 2) Making arrangements for the client to join a diabetic support group 3) Demonstrating blood glucose monitoring and insulin administration to the client 4) Consulting with the dietician about the client's dietary concerns

Demonstrating blood glucose monitoring and insulin administration to the client

The nurse identifies the diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations for a client with an acute respiratory problem resulting from lung disease. Which nursing intervention should be listed first on the care plan? 1) Determine airway adequacy hourly and as needed. 2) Administer oxygen as needed. 3) Monitor arterial blood gas values. 4) Place the client in a high Fowler's position.

Determine airway adequacy hourly and as needed.

The nurse prepares a care plan for a newly admitted client. Why should the nurse review the status of problems prior to writing the interventions? 1) Ensures interventions are concise 2) Identifies the priority of interventions 3) Determines the types of activities needed 4) Validates that all problems have been addressed

Determines the types of activities needed

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the client's main concerns about his diabetes

Determining the client's main concerns about his diabetes

A patient is admitted to the emergency department with a stroke. After the patient has been stabilized, which information should the nurse include in the care plan that best meets the patient's needs? 1) Acute interventions 2) Patient teaching 3) Discharge needs 4) Family health data

Discharge needs

The nurse constructs orders to address a client's health problems. Which statement is an appropriately written nursing order? 1) Walk 100 feet twice a day. 2) Discuss signs and symptoms of postoperative complications. 3) State the reasons to take pain medication before physical therapy. 4) Demonstrate correct technique to self-administer insulin injection.

Discuss signs and symptoms of postoperative complications.

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1) Use an opaque white fluid to cover the documentation error. 2) Completely cover the documentation error with black ink. 3) Draw a line through the error and initial the change. 4) Use correction tape to make the documentation correct.

Draw a line through the error and initial the change.

Which information in a client's health history might indicate a risk for primary hypertension? 1) Consumes a high-protein diet 2) Drinks three to four beers every day 3) Has a family history of kidney disease 4) Does not engage in physical exercise

Drinks three to four beers every day

A client, newly diagnosed with cancer, questions the existence of God. Which action should the nurse take to help this client with Spiritual Distress? 1) Ask the client to explain his feelings about God. 2) Encourage the client to talk more about his feelings. 3) Suggest to the client that his previous beliefs have been wrong. 4) Remind the client that everyone has a different perception of God.

Encourage the client to talk more about his feelings.

Which nursing intervention is considered an independent intervention? 1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain

Encouraging the postoperative client to perform coughing and deep breathing exercises

The nurse reviews orders to address a client's health problems and then edits out words and phrases after writing them. Why did the nurse reduce the length of the written orders? 1) Ensures clarity 2) Measures etiology 3) Supports prioritization 4) Assesses for completeness

Ensures clarity

The nurse documents that a client's nasogastric tube has been removed. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis

Evaluation

When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour

Every hour

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patient's care? 1) Every 2 weeks 2) Every shift 3) Every week 4) Every 3 months

Every shift

A client's radial pulse is full and bounding. Which nursing diagnosis should the nurse select to address this clinical finding? 1) Excess fluid volume 2) Deficient fluid volume 3) Decreased cardiac output 4) Ineffective tissue perfusion

Excess fluid volume

Which intervention depends almost entirely on the client's adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet

Following a low-fat, low-calorie diet

The nurse notes that a risk management nurse reviews the medical records of several clients on a care area. For what purpose is this review being performed? 1) Calculating the cost of care 2) Monitoring health status over time 3) Gathering data for clinical research 4) Determining whether interventions were appropriate

Gathering data for clinical research

For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? 1) Recovering from abdominal surgery 2 hours ago 2) Experienced a fractured hip yesterday 3) Dehydrated from vomiting 4) History of heart and lung disease

History of heart and lung disease

The staff development trainer prepares an educational program on selecting client care interventions. What should the trainer explain as the goal of using evidence-based practice for client care? 1) Select the best care provider to address a client's needs. 2) Choose strategies that reduce the length of hospitalization. 3) Implement approaches that have been proved to improve a client's health. 4) Identify effective and cost-efficient treatments for a particular health issue.

Identify effective and cost-efficient treatments for a particular health issue.

The nurse identifies the diagnosis of Acute Pain related to the postoperative abdominal incision and writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? 1) Collaborative 2) Interdependent 3) Dependent 4) Independent

Independent

The nurse notes that a client's respiratory rate is 30 and irregular. Which nursing diagnosis should be identified to help guide this client's care? 1) Anxiety 2) Altered oxygenation level 3) Risk for poor oxygenation 4) Ineffective breathing pattern

Ineffective breathing pattern

The nurse administers heparin 5,000 units subcutaneously at 2100 and documents in the medication administration record (MAR) that the dose was administered. What other information is important for the nurse to document? 1) Injection site 2) Previous site of administration 3) Patient response to medication 4) Heart rate prior to administration

Injection site

Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process

Intermittent

Before inserting a nasogastric tube, the nurse reassures the client. Which type of skill did the nurse use to help this client? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking

Interpersonal

Which theorist developed the nursing theory known as the science of human caring? 1) Florence Nightingale 2) Patricia Benner 3) Jean Watson 4) Nola Pender

Jean Watson

A client with respiratory failure is experiencing cyanosis and labored breathing. What action should the nurse take first? 1) Study the discharge plan. 2) Check the graphic data for vital signs. 3) Examine the history and physical. 4) Look for an advance directive.

Look for an advance directive.

During an admission assessment the nurse learns that a client has an allergy to penicillin. Where should the nurse document this information after including it in a note in the medical record? 1) MAR 2) Kardex® 3) Bedside clipboard 4) Above the client's bed

MAR

A client who emigrated from India asks whether garlic can be administered through a nasogastric tube that is placed to decompress the stomach. The nurse agrees to ask the healthcare provider if this can be done. Whose nursing theory is the nurse implementing? 1) Betty Neuman 2) Dorothea Orem 3) Callista Roy 4) Madeline Leininger

Madeline Leininger

Which commonly accepted practice came out of the Framingham study? 1) Mammography in breast cancer screening 2) Colonoscopy in colon cancer screening 3) Pap testing in cervical cancer screening 4) Digital rectal examination in prostate cancer screening

Mammography in breast cancer screening

The nurse writes the diagnosis Deficient Fluid Volume related to excessive fluid loss for a client. The goal "The client will maintain urine output of at least 30 mL/hour" is identified. Which nursing intervention would directly help achieve or evaluate the stated goal? Select all that apply. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer IV fluids as prescribed. 4) Keep oral fluids within the patient's reach, and encourage the patient to drink. 5) Measure daily weights every morning.

Measure and record urine output every hour; report an output of less than 30 mL/hour. Administer IV fluids as prescribed. Keep oral fluids within the patient's reach, and encourage the patient to drink.

During a clinic interview, a client states experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1) Ask the client when in the day dizziness occurs. 2) Help the client to assume a recumbent position. 3) Measure both heart rate and blood pressure with the client standing. 4) Measure vital signs with the client supine, sitting, and standing.

Measure vital signs with the client supine, sitting, and standing.

In evaluating a client's blood pressure for hypertension, what is the most important action for the nurse to take? 1) Use the same type of manometer each time. 2) Auscultate all five Korotkoff sounds. 3) Measure the blood pressure in both arms. 4) Monitor the blood pressure for a pattern.

Monitor the blood pressure for a pattern.

Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

he patient's medical record contains the following documentation: 06/05/17 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via 18-gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann Davids, RN Which type of charting has the nurse used? 1) Narrative 2) Focus 3) SOAP 4) PIE

Narrative

The patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT. Where should the nurse look to determine whether the medication was provided and the patient's response? 1) Progress notes 2) Graphic record 3) Narrative notes 4) MAR

Narrative notes

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? 1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift

Nurse who delegated the task

What was Hildegard Peplau's major contribution to nursing? 1) Transcultural nursing 2) Health promotion 3) Nurse-patient relationship 4) Holistic comfort

Nurse-patient relationship

A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1°F to 100.8°F to obtain an oral equivalent. 2) Add 2°F to 100.8°F to obtain a rectal equivalent. 3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading.

Obtain a rectal temperature reading.

Which standardized intervention vocabulary was designed specifically for community health nurses? 1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice

Omaha System

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. How should the nurse document the patient's fall? 1) Patient found on floor in pain after falling out of bed. 2) Patient found on floor after falling out of bed; found by NAP Smith. 3) Patient fell out of bed but is currently in bed. 4) Patient reminded to not climb OOB after falling.

Patient found on floor after falling out of bed; found by NAP Smith.

A patient refuses a dose of medication. How should the nurse document the event? 1) Patient is uncooperative and refuses the prescribed dose of digoxin. 2) Patient refuses the 0900 dose of digoxin. 3) Patient is belligerent and argumentative and refuses the 0900 dose of digoxin. 4) 0900 dose of digoxin not given.

Patient refuses the 0900 dose of digoxin.

A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should be completed next? 1) Perform a literature review. 2) Develop a conceptual framework. 3) Formulate the hypothesis. 4) Define the study variables.

Perform a literature review.

After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's hierarchy of needs, cardiac rehabilitation most directly addresses which need? 1) Safety and security 2) Physiological 3) Self-actualization 4) Self-esteem

Physiological

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1) Hypertension 2) Rheumatoid arthritis 3) Postoperative colon resection 4) Follow all three plans

Postoperative colon resection

. A client recovering from colon surgery refuses to look at the site of a newly placed ostomy. What should the nurse do about teaching this client self-care as identified on the critical pathway? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site.

Postpone the teaching session until the patient is more receptive.

The nurse instructs a client scheduled for surgery on deep breathing and coughing exercises even though the client has no history of respiratory problems. Which type of nursing intervention did the nurse perform? 1) Health promotion 2) Treatment 3) Prevention 4) Assessment

Prevention

According to Maslow's hierarchy of needs, which patient need should the nurse address first? 1) Protecting the patient against falls 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change

Promoting rest in the critically ill patient

A client experiences acute shortness of breath. Which noninvasive technique should the nurse use to assess this client's arterial oxygen saturation? 1) Pulse oximetry 2) Auscultate breath sounds 3) Count the respiratory rate 4) Arterial blood gas sampling

Pulse oximetry

Which intervention would be appropriate for a client who has a fever? Select all that apply. 1) Put an ice pack on the client's neck and axillae. 2) Provide the client a blanket when he is shivering. 3) Offer the client fluids to drink every 1 to 2 hours. 4) Measure the temperature using a tympanic thermometer. 5) Lower the head of the bed.

Put an ice pack on the client's neck and axillae. Offer the client fluids to drink every 1 to 2 hours.

The nurse plans to explain the difference between qualitative and quantitative research to a group of staff who will be participating in a research study. Which statement should the nurse include during this discussion? Select all that apply. 1) Qualitative data are reported as numbers. 2) Qualitative research uses words from people who have been interviewed. 3) Quantitative research focuses on the lived experience of people. 4) Quantitative research shares the experiences of people in the study. 5) Quantitative research gathers data from subjects to generalize results.

Qualitative research uses words from people who have been interviewed. Quantitative research gathers data from subjects to generalize results.

While reading a journal article, the nurse asks herself these questions: "What is this about overall? Is it true in whole or in part? Does it matter to my practice?" What is this nurse doing? 1) Reading the article analytically 2) Performing a literature review 3) Formulating a searchable question 4) Determining the soundness of the article

Reading the article analytically

Which client would probably have a higher than normal respiratory rate? 1) Recovering from surgery and receiving a narcotic analgesic 2) Recovering from surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Exposed to the cold and is now hypothermic

Recovering from surgery and lost a unit of blood intraoperatively

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? 1) Reduces the time nurses spend charting 2) Addresses the patient's concerns holistically 3) Establishes an ongoing care plan from admission 4) Is most useful when constructing a timeline of events

Reduces the time nurses spend charting

When using electronic care planning, the nurse enters the nursing diagnoses, chooses desired outcomes, and validates data, diagnosis, and goals. What should the nurse do if the computer generates interventions that are not appropriate for the client's needs? 1) Reject them all and type in appropriate interventions. 2) Select the interventions from the program that are most suitable. 3) Ask another nurse to assess the patient and give a recommendation. 4) Restart the computer; it is probably a program malfunction.

Reject them all and type in appropriate interventions.

The client has had a fever, ranging from 99.8°F orally to 103°F orally, over the past 24 hours. How should the nurse classify this fever? 1) Constant 2) Intermittent 3) Relapsing 4) Remittent

Remittent

The nurse receives a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1) Repeat the order to the prescriber even if she believes she understood the order correctly. 2) Immediately notify the pharmacy of the order and verify it with a pharmacist. 3) Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4) Transcribe the order on note paper and verify the dosage in a drug handbook.

Repeat the order to the prescriber even if she believes she understood the order correctly.

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the client's blood pressure and apical pulse. 4) Count the client's respiratory rate for 1 minute.

Request the client take a deep breath and cough.

When caring for a client with a fever, what should the nurse expect to be increased? 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate

Respiratory rate

Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1) Oral temperature 100°F (37.8°C) 2) Respiratory rate 26 breaths/min and shallow 3) Apical heart rate 56 beats/min 4) Blood pressure 124/82 mm Hg

Respiratory rate 26 breaths/min and shallow

For which adult client should the nurse make follow-up observations and monitor the vital signs closely? 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg. 2) Oral temperature is 97.9°F in the morning and 99.8°F in the evening. 3) Heart rate was 76 beats/min before eating and 88 beats/min after eating. 4) Respiratory rate is 16 breaths/min when standing and 18 when lying down.

Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg.

The nurse identifies the diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations for a client with an acute episode of chronic obstructive pulmonary (lung) disease. After establishing care goals, what should the nurse do first when selecting nursing interventions? 1) Identify several interventions likely to achieve the desired outcomes. 2) Review the problem and etiology of the nursing diagnosis. 3) Choose the best interventions for the patient. 4) Review the goals she has written.

Review the problem and etiology of the nursing diagnosis.

Which set of topics makes up a hand-off report given in a recommended format? 1) Data-action-response 2) Subjective-objective-assessment-plan 3) Situation-background-assessment-recommendation 4) Patient-diagnosis-medications-activity

Situation-background-assessment-recommendation

Which definition best describes a critical pathway? 1) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something

Standardized plan of care for frequently occurring conditions

Which behavior provides the most valid criterion for determining the status of a patient's anxiety at discharge? 1) Has a relaxed facial expression 2) States feeling more relaxed today 3) Shows no physiological signs of anxiety 4) Has no further questions about home care

States feeling more relaxed today

The PICO question reads, "Is TENS effective in the management of chronic low-back pain in adults?" Which part of this question comes from the "I" in PICO? 1) Adults 2) Management 3) Pain 4) TENS

TENS

. The nurse reviews a client's care plan, goals, and outcomes prior to discharge. Which type of evaluation is the nurse conducting? 1) Process 2) Ongoing 3) Terminal 4) Intermittent

Terminal

A client is admitted to a long-term care facility. What does the nurse have to use to adhere to federal law? 1) The Minimum Data Set (MDS) for assessment 2) Situation-background-assessment-recommendation (SBAR) for reporting 3) Centers for Medicare and Medicaid Services (CMS) guidelines prior to surgery 4) The Joint Commission guidelines for discharge planning

The Minimum Data Set (MDS) for assessment

The nurse reviews orders written to a client prior to implementation. What should the nurse analyze to ensure that the orders are complete? 1) Whether they are concise 2) The etiology 3) Whether they are prioritized 4) Whether they are individualized

The etiology

Which statement about nursing interventions is true? Select all that apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition. 3) Nursing interventions should be individualized and culturally sensitive. 4) Standardized nursing interventions improve care for a specific client. 5) Computerized interventions are the most succinct and individualized.

The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. Nursing interventions should be individualized and culturally sensitive.

The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still wishes to withdraw. By withdrawing from the study, the mother is exercising which right? 1) Not to be harmed 2) To self-determination 3) To full disclosure 4) Of confidentiality

To self-determination

What is the purpose of completing an occurrence report? 1) Provide a legal defense should the patient seek legal action after an unusual occurrence 2) Track problems and identify areas for quality improvement 3) Report errors to the Food and Drug Administration 4) Report medical errors to The Joint Commission

Track problems and identify areas for quality improvement

Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway

Transferring authority to another person to perform a task in a selected situation

Which task can be delegated to nursing assistive personnel (NAP)? 1) Turn and reposition the client every 2 hours. 2) Assess the client's skin condition. 3) Change pressure ulcer dressings every shift. 4) Apply hydrocolloid dressing to the pressure ulcer.

Turn and reposition the client every 2 hours.

At the conclusion of a research study, the nurse analyzes the data. What action should the nurse take next? 1) Use the findings 2) Select the problem 3) Define the problem 4) Select a research design

Use the findings

The nurse reviews a client's plan of care. What characteristics of criterion should be present before they are used to evaluate a client's care? Select all that apply. 1) Process 2) Validity 3) Structure 4) Outcome 5) Reliability

Validity Reliability

The nurse reviews interventions written to address a client's health problem. What should the nurse know before identifying the independent interventions? Select all that apply. 1) Who 2) Why 3) How 4) When 5) Where

Why 3) How 4) When