Community Health Nursing
A nurse is calculating the protein needs if young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client?
48 g
A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A. "We miss our daughter so much that we are going to move closer to her." B. "I think this year I can plan on managing the funding at church." C. "I really wish I could lose some of this weight." D. " I find I am spending more time at work now that my son is at college."
A. "We miss our daughter so much that we are going to move closer to her."
A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." which of the following actions should the nurse take? A. Assist the client in finding local smoking -cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting
A. Assist the client in finding local smoking -cessation assistance programs
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air fresher in the client's room D. Offer the client ginger tea
A. Encourage the client to listen to soft music
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestation as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis
A. Hemolytic
A nurse is preparing to administer a unit of packed RBCs to a client. which of the following pieces of information must the nurse verify with another nurse prior to the administration? (select all that can apply) A. The clients ID number B. The client's room number C. The client's name D. ABO compatibility E. Rh compatibility
A. The clients ID number C. The client's name D. ABO compatibility E. Rh compatibility
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A: Daily weight B: Blood pressure C: Specific gravity D: Intake and output
A: Daily weight
A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. " I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. " I don't know what I will do if my car isn't safe or even drivable after the crash." D. " I wonder how I am going to be able to take care of my family."
B. " I can't sleep well because whenever I move in my sleep, the pain wakes me up."
A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. " The next time I urinate will be the first specimen of the collection." B. "I'II make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine." D. "It's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the tests."
B. "I'II make sure to keep the collection bottle in the container of ice they gave me."
A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Documentation mild inflammation.
B. Document this as an expected finding
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (select all that apply) A. Gingivitis B. Dry, Brittle hair C. Edema D. Spoon-Shaped nails E. Poor wound healing
B. Dry, Brittle hair C. Edema E. Poor wound healing
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line. B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum
B. Second intercostal space to the left of the sternum
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates that nurse is maintaining sterile technique/ A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora
B. Wiping the labia minora in an anteroposterior direction
A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? A. Hypothalamus B. Cerebral Cortex C. Brainstem D. Cerebellum
C. Brainstem
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which is the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away B. Prepare an incident report to document the event C. Carefully remove the gloves and proceed with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection.
C. Carefully remove the gloves and proceed with hand hygiene
A nurse is teaching a middle-aged female cline about disease prevention and health maintenance. which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? A. Annual Papanicolaou (pap) testing B. Mammogram every 2 years C. Eye examination every 2 years D. Annual Colonoscopy
C. Eye examination every 2 years
A nurse is caring for a client who had a stroke and is a risk of falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints
C. Monitor the client at least once every hour
A nurse is providing discharge teaching to a client who does not speak both the client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. which of the following actions should the nurse take? A. Ask the clients client's neighbor to call a family member to interpret B. Ask the client's neighbor to translate the information C. Obtain the services of an interpreter D. Document the inability to provide discharge instructions
C. Obtain the services of an interpreter
A nurse is measures a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia
C. Tachycardia
A nurse is discussing fire safety with newly hired nurses. which of the following actions is the priority if a fire occurs in the health care facility? A. Close the fire doors on the unit B. use the fire extinguisher on the fire C. pull the nearest fire alarm D. Evacuate clients from the unit
C. pull the nearest fire alarm
A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A: "Now that we have talked about your medications, let's talk about your pain." B: "Are you having other symptoms?" C: "It sounds like your pain is intermittent." D: "It seems s through you have really had a rough time these past few weeks."
C: "It sounds like your pain is intermittent."
A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods. "Which of the following statements should the nurse make? A: "During this phase, feed your child anything that she will eat." B: "Increase that amount of calories and water your child consumes." C: "Keep a diary of the fo0ds your child eats each day." D: "Provides a large variety of fruit juices for your child to choose from."
C: "Keep a diary of the fo0ds your child eats each day."
A nurse is measuring a client's vital signs and notice an irregularity in the pulse. Which of the following actions should the nurse take? A: Measure the pulse using a Doppler ultrasound stethoscope B: Check the client's pedal pulses C: Counts the client's pedal pulses rate for 1 full min and describe the rhythm in the chart D: Take the pulse at each peripheral site and count the rate for 30 sec
C: Counts the client's pedal pulses rate for 1 full min and describe the rhythm in the chart
A nurse is assessing a client's peripheral pluses. Which of the following descriptions should the nurse use to document the findings? A: Peripheral pulses equal bilaterally at a rate of 60/min B: Radial, brachial, and pedal pulses bilaterally weak C: Peripheral pulses bilaterally symmetric, equal and strong in all 4 extremities D: Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable
C: Peripheral pulses bilaterally symmetric, equal and strong in all 4 extremities
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures." D. "What worries you about being without your teeth?"
D. "What worries you about being without your teeth?"
A nurse is supervising a newly licensed nurse is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure/ A. Using clean technique to preform the procedure B. Applying suction while inserting the catheter C. Lubricating the suction catheter with an oil - based lubricating jelly D. Administering high-flow oxygen prior to the procedure
D. Administering high-flow oxygen prior to the procedure
A provider is planning an immunization clinic for older adults. at which of the following times should an older adult client receive the influenza vaccine? A. Once during the client's lifetime B. Every 10 years C. Every 5 years D. Annually in the fall
D. Annually in the fall
A nurse is caring for a client who is having difficulty with muscle coodination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum
D. Cerebellum
a nurse is planning to provide document care provided for a client. Which of the finding abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half -strength
C. PC for after meals
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction catheter back 1 cm (0.5 cm) if the client starts coughing B. Allow 30sec between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 sec D. Perform a maximum of 4 passes with the suction catheter
A. Pull suction catheter back 1 cm (0.5 cm) if the client starts coughing
A nurse is teaching assistive personal (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? A: Elevating the finger above the heart level B: Rubbing the fingertip with an alcohol pad C: Puncturing the side of the fingertip D:Wrapping the finger in the warm cloth
A: Elevating the finger above the heart level
A nurse is measuring a client's vital signs. The client's resting radial pulse is at the rate of 55/min. which of the following actions should the nurse take next? A: Document the finding B: Measure the client's apical pulse rate C: Talk with the client about the factors that can affect pulse rate D: Notify the provider about the client's radial pulse rate
B: Measure the client's apical pulse rate
A nurse is caring for a client who has stage 3 pressure ulcer on he heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity
C. Check the client's pain level
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employee's children at an acute care facility. Which of the following activists should the nurse includes as an example of concrete operational thinking? A. Playing in the sand B. Playing dress-up with old clothes C. Collecting and trading card games D. Describing interpersonal relationships
C. Collecting and trading card games
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia
C. Decreased cardiac output
A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance
C. Depression
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pin from the extinguisher D. Sweep the hose from side to side to dispense material
C. Remove the safety pin from the extinguisher
A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Client's level of comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the client's recent illness D. Sociocultural history
A. Client's level of comfort and ability to participate in the interview
A nurse is reviewing the laboratory values of a client who has positive Chvostek's sign. Which of the following should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium
A. Decreased calcium
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when installing the eye drops? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 cm (0.2 in ) from the cornea D. Instruct the client to close the eyes tightly after administration
A. Drop the eye medication into the lower conjunctival sac
A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein/ A. Eggs B. Cereal C. Peanut butter D. Pasta
A. Eggs
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A. Inspection B. Auscultation C. Percussion D. Palpation
A. Inspection
A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. Lactose B. Sucrose C. Maltose D. Fructose
A. Lactose
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection/ A. WBC 15,000 mm^3 B. Erythromycin sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063
A. WBC 15,000 mm^3
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated? A: Cover the incision with a moist sterile dressing B: Have the client lie on his back with his knees flexed C: Call the client's surgeon D: Reassure the client
A: Cover the incision with a moist sterile dressing
A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night - light in the hallway." C. "I will put on socks when I get out of bed." D. " I will secure any wires in my home under rugs."
B. "I will put a night - light in the hallway."
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A: Push on a fingernail bed until it blanches, releases it, and observe how long it takes the skin to become pink B: Grasp a skin fold on the chest under the clavicle, release it, and note that weather it springs back C: Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression. D:Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers
B: Grasp a skin fold on the chest under the clavicle, release it, and note that weather it springs back
A nurse is caring for a semiconscious client who has a small -bore NG tube placed yesterday for the administration of enteral feeding methods should the nurse use to verify correct tube placement (select all that apply) A: Auscultate injected air B: Verify the initial x-ray C: Measure the length of the exposed tube D. Determine the pH of aspirated fluid E: Check the aspirated fluid for glucose
B: Verify the initial x-ray C: Measure the length of the exposed tube D. Determine the pH of aspirated fluid
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum
D. Check the client's perineum
A nurse is caring for a client who had a mastectomy and has a self -suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device to remove air after emptying
D. Collapse the device to remove air after emptying
A client's who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly. B. Instruct the client to avoid using a facial tissue after instillation C. Remind the client to avoid using a facial tissue after instillation D. Instruct the client to apply pressure to the inside corner of the eye after instillation
D. Instruct the client to apply pressure to the inside corner of the eye after instillation
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side -lying position C. Provided privacy D. Lower the client to the floor
D. Lower the client to the floor
A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation
D. Palpation
A nurse is performing a physical assessment of a client. which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines. C. Palpate for respiratory excursion D. Perform a blanch test
D. Perform a blanch test
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classification? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders
D. Plasma volume expanders
A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? A. Smear the small amount of blood onto the testing strip B. Hold the finger above the heart level C. Massage the client's fingertip D. Wrap the client's finger in a warm washcloth
D. Wrap the client's finger in a warm washcloth
a nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. the nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. respiratory depression D. liver damage
D. liver damage
A nurse is caring for a middle-age adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? A: Managing a home B: Establishing a sense of self in the adult world C: Forming a new friendships D: Ceasing to compare personal identity with others
D: Ceasing to compare personal identity with others
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A: Tell the client it is too late for her to change her mind because the surgery is already scheduled B: Telephone the operating room and cancel the surgery C: Inform the client's family about the situation D: Notify the provider of the client's decision
D: Notify the provider of the client's decision
A nurse is teaching a group of young adults. which of the following should the nurse identify as an expected developmental task for this age group? A: Independent moral development B: Acceptance of body changes C: Strengthening ties with the family of origin D: Development of concrete reasoning
A: Independent moral development
A nurse is caring for client who reports using several herbal medications. Which of the following actions should the nurse take? A: Discourage the use of unregulated medications and supplements B: Verify the herbal supplements do not interact with medications the provider has prescribed C: Tell the client to limit the number of herbal supplements to no more than 2 D: Described the dangers of taking plant - derived medications and supplements
B: Verify the herbal supplements do not interact with medications the provider has prescribed
